Laserfiche WebLink
�8J EV � '� <br /> TORT CLAIN!FORM OCT 11 2013 <br /> ".�.���09 �TY OF EV��.�T'd' <br /> Pursuan[ to Chapter 4.96 of Ihe Revlsed Cade of Washington(RCV�, �'1}f� �`i�,k <br /> this farm is for filing a tort dalm agalnst the Clty of Everett. Some of `J <br /> the Informatlon requested on Ihls Wrm is reqWred by RCVJ 4.96.020 <br /> and may be subJeR to puhlic disdosure. Thc Gty Clcrk Is the City's Gt�'QeMCiaimNo. <br /> deslgnated agent for lhe purpose of receiving clalms. C(alni /nrms �a� ' I �� <br /> cannot be snbmlKed e%dronlca//y(vla e-msl/or/ax). <br /> G�ao�3o0�! <br /> VLEASE TYPE OR PRINT CLEARLY`.IN INK ' � � . � � � . I 3 <br /> r' <br /> Mall or deliver odginal signed clafm form to: OHice of the City Clerk - . <br /> City of Everett� <br /> Business Hours: 2930 Wetmore Ave.,Ste,1-A <br /> Man.—Frl.,8 a.m.to 5 p.m.,Pa[Ific Time EvereN,WA 98201 <br /> Closed on clry holidays <br /> CLAIMAN7INFORMATION: <br /> 1.Clalmant's name: - <br /> IY19Daon2 assoua46s 1.�. , LLC n�A <br /> Last name flrst M/dd,e Aale olb/Rh(mrry/dQ/yyyy) <br /> 2.Nrrent reslAentlal aAdress: h�a — <br /> 3.Mailiny address Qf dlfferent): 5�✓� SPo�^E��E� �2���e�� 98Z5�' — <br /> q.Residential address a[the time of the Incldent(If different from current address): <br /> h/a <br /> 5.Clalmant's telephone number: '�i5•Z3(•45oS 4u'3�4•�-�'�4 <br /> Nomc Cc1/ Buslness <br /> 6.e�a�manCs e-ma�l adAress: G�M9mT G� .}eFao enm <br /> INLIDENTINFORMATION: <br /> 7.Dale o(InddenL• __ _ Tlme: ❑a.m. ❑p.m. (check one) <br /> (mMdd/nri) <br /> 8.If Ihe Intident otcurred over a pedod of time,date of Orst and last occwmn � <br /> (runr���'ze�}_ nmc: 5 ❑a.m. Q�p.m.(check onc) to ��'O1� 71mc: 5 ❑a.m. Li�m.(chak onc) <br /> (mm�dWvm') I (mnVduhYtY) mad¢ona 1aiQ�m...cy <br /> 9.Localionoflncldent: ""a9Mincy���ouorr��sH ,_EJ6Rd �37-iZ.aek�ca�snuc <br /> Sfu(e 9nd moaty CRy,ilaOP'itaLJe P,Ucc ivAcm orcuircrJ <br /> 10.If lhe incident acurred on a slreet or hl9hwayc <br /> ��a <br /> ld�me olsUn�l or h�y0way Rt fhr Intcrsarian�NM amar t/nhrrttNig.Ntt'7 <br /> Rav.01109 <br />