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� Cllyot Ev�ntl Usa 0nly <br /> TOR7'CLe4Il�FQR/N <br /> R��EI��� , <br /> ew.u�/09 AUG 3 0 �n�� <br /> Pursuant ta Chapber 4,96 of the Revlsed Code of Wasfiingmn (RCW), � t_,,,.,�, <br /> this Fortn ts for filing a mrt claim against the City of Everett. Some of CTTY 6�F �Vr�;G;, ; <br /> the informatfon requestecl on this form Is required by RCW 4.96.020 (',j�r {`j,y��, <br /> and may be sub)ed to public discfosure. The Ciry Clerk ts the Clty's CiryClerkCleim �o. <br /> designated agent for the purpose of receiving claims. Claim forms <br /> �nnot be submiked elecirortia/ly(v/a e-maflorlax). �D�'�'� <br /> ALEASE TYPE OR PRINT CLF.�qLY IN INK ! <br /> Mall or dellver ori9lnal slpned claim(orm Oa: Offiaa of tha Ciry Cierk <br /> City of Everott <br /> Buslnesa Hours: 293R Wednore Ave,,Ste. i•A <br /> Mon,—Fri.,8 a.m.to 5 p.m.,padfic Time Elrerctt,WA 98I01 <br /> Clomed on dty holidays <br /> CIAiMANT INFORMATIOPI; <br /> 1. Clafmant's name: <br /> McCOI l ur� - I� l—�-00. --�2 — I l �k�L�'� <br /> �Bst narne F/rst Midd/e Date bl�th(m.'n/ddM11') <br /> � L ��,,�`� <br /> 2. Current residenHal eddres�: �"1 �'��"' T��('(�(.CQ�r,__ 1.�v� ��_�03 <br /> 3. Malling address(If different): �m�` <br /> 4. Resldentlal address at the time oF the InNdeat(if different hnm arrent adQress): <br /> Sd��- - - <br /> � N�A ��s_4��4—i 4�` _ � <br /> S. Clalmanlstelephonenumber: 3{���JSq-��O � <br /> y� Ce/l Busine�s I <br /> 6, Claimant'se•mailaddr.ss: ��Qh����. . m�c-Cplll,�mcc_yC�,hp�r-��']--_.- ___. <br /> �l <br /> N�CIDENT INFORMATION: <br /> 7, Date of incident: O C�i f a OI�____ Tme: 5�•� 1]a.m..�p.m. (dieck one) <br /> (mi��dd!YYVY) <br /> 8. If the inctden oaurred over n period of t(me, date of first and lest ur nces: <br /> 6om:�a I 3 '{ime: S:3� i�a.m. �p.m.(check one) to � �.3 Time: ''3� ❑a.m.�p.m.(check o�re) <br /> (mm/tld/YVYV) (mm/d IYYYY) <br /> 9. Laationofincldent: _�/�IaS�11 h � f� �ohomish �J"�,� _l�Qa. T� rVY r��Y'• <br /> .Rate and awn�-- OCy lfapplirabk fi�re where a�mad <br /> ]0. if[he inddent oaurred on a street or highway. <br /> ��.....__--.�NanMa✓shlL^lOrAlghwdy � Attl�eJnlasntionNlMd�ne.vms!/nfr�Im.Azr! <br /> i <br /> 1 % <br />