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Ever <br />RttCEIVl <br />OL TORT CLAIM FORM SEP 16 2013 <br />new. 07109 <br />Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), <br />this fomr Is for filing a tort claim against the City of Everett. Some of <br />the Informatlon requested on this form Is required by RCW 4.96.020 <br />and may be subject to mlblic disclosure. The City Clerk Is the City's <br />designated agent for the purpose of receiving claims. Claim forms <br />cannotbe submitted electronically (via a -mall or fax). <br />PLEASE TYPE OR PRINT:CLEARLY-IN INK <br />Mail or deliver original signed claim form to: <br />Business Hours: <br />Mon. — Fri., a a.m. to 5 p.m., Pacific Time <br />Closed on city holidays <br />1. Cialmant'sooname: <br />Lew,\no1owsI'1 <br />lastname <br />2. Current residential address: <br />3. Mailing address (if different): <br />CITY OF E`dERETT <br />City Clctr�-. <br />Cily Clork Claim No. <br />[: )140 - 13 <br />office of the City Clerk <br />City of Everett <br />2930 Wetmore Ave., Ste.1-A <br />Everett, WA 98201 <br />ctt / <br />FiW Middle Date <br />2�26 WoInt&S+-. Svc(-J-,WA- q�zaI <br />4. Residential address at the time of the Incident (if different from current address): <br />5. Claimant's telephone number: <br />6. Claimant's a -mall address: <br />INCIDENT INFORMATION: <br />7. Date of Incident: _ a-Ef.Z S 13 <br />(mm/dd/yyyy) <br />Pl /Igsf3 <br />2yb 779-SSr1 5r <br />Cell Business <br />Time: ^' �' "t70 ❑ a.m. f i p.m. (check one) <br />R. If the Incident occurred over a period of time, date of first and last occurrences: <br />from: ._.._ Time: 11 a.m. ❑ p.m. (check one) to _ Time: <br />(mm/ddlyvw) (mmldd/yyyy) <br />2126 W.It,k - M- <br />Plate where occurred <br />9. Location of Incident: <br />WA Syv�o+,rS� <br />ON, <br />❑ a.m. ❑ p.m. (check one) <br />10. if the Incident occurred on a street or highway: <br />Al cl�Cmorhlghxay At the /nhrsertlon wi.* orneawlt/ntametlngSteel <br />Rev, 07109 <br />