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...:�..—�;_� , <br /> ., CltyolEvaretlUsaOniy � ' <br /> RE.C�I�T�I� � ; <br /> �` -�����' � TORTCLAtMFORM � <br /> Rev.07/03.. i SEP o �i 2013 � <br /> i <br /> Pursuant to Chapter q.96 of thc Revised Code of Washington (ACW), Gk�'ll�F EV��iEZ"� I�,� <br /> this form ISfor Flling a tort daim against the Ciry of Everelt. Semc of �.,�" , I <br /> the inFormalion rcqucsled on this form Is requlred by F�qN 4.96,020 __ ��� Clal[ ` ; <br /> and may be subJect lo public disclosure. Tlie City Clerk is the City's . ciycieniaaimNo: --� �' <br /> de5ignated agent for the purpose of receiving daims. C/aim lorms _�.�� _ '� <br /> cvnno!be submilteG elecfronica//y(v/a e-ma!!or fax). � . _ „ <br /> P,LEASEiTY,P,E�:UR:PRIN,T,CLI�J1�tLY:IN,INK.� '. .'t? .. . .. ., . �. . . . .:�' .. . . - .. -�r��I � , <br /> Mall or dellverorlginal signetl clafm form to: Office of the City Gerk � <br /> City of Everett <br /> 8usiness Hours: 2930 Wetmore Ave.,Ste. 2-A <br /> Man,—Ftt,8 a.m,to 5 p,in,;.pacific 7ime Everett,WA 98201 <br /> Closed on city holidays <br /> CLA7MANT INF4RMATION� ; <br /> 1.Claimant's name: <br /> .._�f�i�1-�C�.. _._ I��I �;1}��h�� ._,�7J.U� <br /> lastixame — �- . ..'. ...�. !'irst _ . . . - �Pf%dd/a . _. D.rfco�brrth(mm/AdMYY) .. <br /> 2.Current residential addresst :�S 1 I . , . R��_����V�. <br /> 3.Plailing address(if different):. ;_ , , <br /> 4.Residentlal address at the tlme oF the fnctdetit(if different(rom arrent address):, , . <br /> __, .. _, .. �.. ,.._: i <br /> _.._ -.___.,_:.��_—_—_ . <br /> _._ <br /> u.CfaimanL's telephone number. "1�5 -J�7 '�zdZ- ' <br /> . .' HiinlC�_. `�.- Cell Businets <br /> G.Claimant's e-mail addr�ss; „�.�4?�LI�.�`����_.u?Y`^� .__. T - _., <br /> INCIDENTINFORMA7i0N: <br /> 7.Da�e aF Incident: .T� T L�. ZO I _� 'Tme: ���___,O a.m, I�`p.m. (check one) � <br /> (nnnJJ:l/vyYY1 �.5 CO lI e�,�� <br /> 6.If tlie Incldent occurred over a perlod of Lfine,date of first and last acurrences: <br /> from:. Time:.___0 a.m. 0 p.m.(check one) to�.�,__,^'ilme:._____�a.m. �p.m.(chc�k enc) ' <br /> � (mm)dd(yyyyj (mm/ddhryyy) <br /> 9.Lacadonofincldent: �7T��0 s 7A.,__ _U �E-fi_,..,. �5l/ I�urY-�2 . <br /> Stafe and couaty Gry;rfappJrcab,'e P/are whe�e ottuia�d ���� <br /> 10. IF the inddent accurred on a sheef or highway: <br /> I <br /> � Nanicolsbeeforh;9hiray Alfheln(m�echA�w77hrYneamALaMrSCUirlqs7reet � I <br /> �� Z � <br />