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4rr <br />TORT CLAIIM FORM <br />Rev. o' <br />Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), <br />tills form Is for filing a tort claim against the City of Everett. Some of <br />the Information requested on this form Is required by RCW 4.96.020 <br />and may he subject to public disclosure. The City Clerk Is the Clty's <br />designated agent for the purpose of receiving claims. C1.71nr forms <br />canrro[be submllred eleclranlcally(vla o-mall orf K). <br />OCT 01 2ou <br />WY OF EVERETT <br />C1tq Clerk <br />Clly clerk claim No. <br />n;)-C9`-13 <br />GCaol300gUD;k <br />PLEA$E7:yPE Ofi�PRIXX�I .T CLEARLY•`IN INI(; ,•ii _ ' t,.'<. ,e�.-.+L<^+i-.'<<sYs+1,+'.��c <br />Mail or, deliver original signed claim form to: office. of the City Clerk <br />City of Everett <br />Business Hours: 2930 Wetmore Ave., Ste. 1-A <br />Mon. - Fri., B.I.M. to 5 p.m., Pacific Time Everett, WA 98201 <br />Closed on city holidays <br />CLAIMANT INFORMATION: <br />1. Claimant's name: <br />last name <br />flrsf <br />Middle 1171e <br />2. Current residential address; _ (G12�/ N//� fj UC— �Y7 T 119�- f% oho <br />3. Malling address (if different): / <br />A. Residential address at the time of the Incident (if different from current address): <br />5. Claimant's telephone number: <br />Name Gbll Nuslr>css <br />6. Claimant's e•mall address: _— - - - ----- <br />INCIDENTINFORMATION: <br />7. Date of Incident: Time :.__ �. ❑ a.m. R P.m. (dieck one) <br />(mm/dd/ri") <br />0. If the, Incident occurred over a period of time, date of first and last occurrences: <br />fmm: zV a9-i3 Thnm; U a.m. W p.m. (check one) to e9--VS_�3lme: __❑ a.m. 19 p.m. (check one) <br />(mnVddlyyvy) (mmlddIM) <br />9. Location of Incident: WA -- �NOHDM I S/94 45✓C�� � .,J118 V2'CeSr'uf'¢ <br />Stale andmunry Ory, If applicable Plan oficre oxtiaro' <br />10. If the Incident occurred on a street or highway: <br />Namenfshw1ah0nay At the lnteas fw Rill, or mwstlnlemA SIh t <br />Rev. 07109 <br />