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� <br />� <br />�.�i� <br />TORT CLAIlN FORM <br />Pursuant to Chapter 4.96 of lfie Revised Code oF Washingtan (RCW), <br />tl�ts fortn is for filing a tor[ daim against the Crty of Everelt Some of <br />the Infortnatlon requested on this form Is required by RCW 9.96.020 <br />and may be subject to pudic dis�iosure. The Gty fJerk is the GqJs <br />detiignated agEvrt fa the purpose of receiving daims. dafm fomRs <br />onnol de wbmilted eJecb�vnira/ty (via e-mai/orfax). <br />.- - ... . ... .... __ . <br />�PIEASE:TYPE :OR PRINT CLEARLY : IN' INK <br />(.tiry oi EnnaM Usa Ony <br />����� 1 N� <br />SEP o 4 2ot3 <br />CITY OF EVERET'l' <br />Ciiq Clerk <br />Cily CIcAc Claim No. <br />���- - � 3 <br />n �i3oo �y <br />Mail or detiver original signed claim form to: O�ce oF the City Clerk <br />City of Everett <br />Bustness i:uurs: 2930 Wetmore Ave., Ste. 1-A <br />Mon. — Fri., 8 a.m. to 5 p.m., Pacific Time Everett, WA 98201 <br />Closed on city halidays <br />CLAIMANT INFORMATION: <br />1. Claiman['s name: <br />A4yslak Henryk F <br />Last name Fin7 Midd/e <br />2. Current resldential address: 5030 Rucker Avenue Everetl, Wa <br />3. Mailing address (If different}: <br />4. Residenti,l address at the time of lhe Incident (If different trom current address): <br />1011011953 <br />Date of blrth (mm/dd/ryryJ <br />5. Claimant's telephone numbcr: 4z5-317-8781 425-220-6022 <br />Home Ccll Busi�iess <br />6. Claimanl's e.-mail address: henrykmyslak@msn.com _ __ <br />INCIDENTINFORMATION: <br />7. Datc af incident: 0129/2013 <br />(mm/AA/yyyy) <br />Timc : �:00-6:00 <br />8. If the incidenl occurred over a period o( tirnq date of first and last occurrences: <br />Gom: Timc: __ U a.m. ❑ pen. (check one) to Time: <br />(mmJdd/yyyy) <br />(mm/Cd/yyryj <br />_ ❑ a.m. � p.m. (chetk ane) <br />❑ a.m. ❑ p.m. (check anc) <br />9. Location of Incident: Washin tanlSnohomish Evere�l Residence _ <br />Sla�r and rounty 6ty, ifapplic�ble Plam �vhe�e octtvred <br />l0. IF the Incldent occurced on a street or h(ghway: <br />Name olshce: orhlghu3y A( !hc hHencetlon w;flr or ncamsfln(ersttiin9 strt^ef <br />Rev. 07109 _ <br />I�� <br />