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. ._ _ . . _.... <br /> ' cnyoieuoronu.00niy � <br /> RECEI��D ' � <br /> =' TORT CLAIM FORM <br /> p.�.o,ro9 - SEP 23 2013 <br /> � <br /> Pur;uant to Chag[er 4.96 pf thc Revlsed Code o(VJashingtan (RCIV), � ��xY OF �VE�tE1"f � <br /> this form Is for tlling a tort clalm agalnst ffie Clty of Everett. Somc of . �� <br /> lhc InFormation requested on thls form Is mqulred by R� 4•96�.020 _.__ ('{tp ('f p�.�_ ' � <br /> and may be subJed lo publlc disdosure. The City Clerk Is lhe City's ciyc�ertci�im : �' <br /> deslgnated agent for the purpose ot recelving ctafms, CYa/m (orms �I�7 k, ..I� <br /> cannotbesubmitteddettronical/y(v/ae•m�i/orfax). � �� �1 � _. <br /> . vl..o7d � � . <br /> r,r-�.. �.-- � - a � 1� L - a1. � ..� . . ♦• e v � � q <br /> .l�LEQS�T�IP,6�ORT�I'�C4�A�Y�INfTN��.'.: qv�.���.54..�:��.e ' � .t ''.S''� ��..M1� .K! �s �� .°...:� K^ri i i':'<,'�1 <br /> ' _. . . . . . . .. , i <br /> Mall or deliver original stgnetl claim fotm to; OKce of tha tlty Cicrk . <br /> dty oT EvCreK <br /> 6usiness Houn: 2930 We[more Avc.,Stc. 1•A � <br /> Mon.—Fri.,8 a.nr.fo S p.m.;Pacific 7ime Everett,WA 98201 <br /> Closed on city holidaya ' <br /> I <br /> CLAIMANTINFORMATION: <br /> i I <br /> i.Claimant's name: f� <br /> _... . _ , SO�� : _ I18� � �/�,S �`f�i3 <br /> 7ast name " �—' �' �`� �f/rsi -" � AtiA,�le � �/� �� bule ofDlrth(mrt�/Cq/yyyyJ <br /> 2.Curren[resldenUal address; ��d��7.. ��fl�Q LC� . /J�\ CV elH P� �`�1�_9d°�� <br /> 3.Malling address(If dlRerent): �, ��i�� yy� L lJ��'�C'' '1� 'W� �O�.�� `i <br /> 4.ResiAential address a[tha tlme of the Inddent Qf diRerent from turrent address); � <br /> � <br /> � — i <br /> ._,.,........_., ..Q_!_�;1.. .__.. ._. ... _ — <br /> . _ J. _ _.__ . <br /> ;.C(a(manPs telepMone number. "_,,,_,"_, �J-�S- 3�0 -��6� � <br /> _._,__._.___� _ _ <br /> _ , <br /> mxeI' � Ce!! Bus/ness <br /> 6.Clalman['se•mailaddr�s5: ,.��.�y1 �S�hln �� C���tiic�S�..._.��'_ � <br /> �NCIGENTINFORA,LATION: <br /> A Date of�h�ddenF. ,�D ��.�� ��_GY,,,�3 �Time:.�% �v .,0 a.m.,F�p.m. (theck one) i <br /> (mn�dWYYYYI i <br /> ��I(�Hir�ntident occurred over a pedod of tlme,date o/Oist and last ocarrenc�; E <br /> ham:� � - � llme: ❑a.m. Cl p.m.(d�eck one) to Tlme; LI a.m. U p.m.(check o�e) <br /> -(r1m/dd�yyvyy� � (min�dd/yyry) � ; <br /> �(.,� ! 6 rc✓'r^c,.C:e . (' (% L VC'i�e��..i�{!/� _.`��:��� <br /> 9.Locatlon of Inddent: � <br /> S;�fe and munry ��4appDwb'e Plare���here ncr.u. + � � ' <br /> 1 <br /> 10.IF the Incldent occurred on a sUee[ar hlghway: <br /> � A'eineol.she�e[ahyAi�ay Attlminferscclim�wM�o/n[vmstlnfersrctingsfree! � . <br /> l,�a <br />