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�`������D <br /> TORT CLAIM FORM SEP 13 2ot3 <br /> Prv.07/09 CII'FY OF EVER�TT <br /> Purwant tn Chapter 4.96 of tfie Revi^�od Code of We�ington (RCW), <br /> thls form Ls for filing a tort clalm against tfie Gry of Everett. Some of C��C1Ct'�( <br /> the Infotmatlon requested on th(s Form k required hy RCW 4.96.020 <br /> aad may be subject to publlc disdosure. The Giry Cledc Is the Citys c�ryaencoeenna <br /> deslgnated agent for the purpose of receiving claims. daim lomrs 1� I�� ' �� <br /> canno!be submitted eledronicxlly(via e•mail or faxJ. <br /> C,e o� ooyy9 7 <br /> h,LEASEYYhEbRPRIN7.C#EAkLY+IN INK- � ` ', . �'''-, � :` . • �. ,:;% . _ <br /> Mafl ordeliver original signed claim form tu: Office of the Ciry Clerk <br /> City of Everett � <br /> Business fiours: 2930 Watmor¢Ave.,Ste.i-A <br /> Mon.—FM„Ba,m.to5p.m.,PacificTlme Everett,WA96201 <br /> Closed on dty holldays <br /> CLAIMAN7IN FORMATION: <br /> 1.Cleimant's neme: <br /> �S�vr,ari Jo�n IV1, 8 a� r9sz <br /> Cast eme I F/�st /� �� M/dv� Oak olb/ (m�/dd/yyyyJ <br /> 2.Current residential address: l'J�� t�/aY�1r�91 �'1'�/�i , '�_1__Vef�°i 11 �/r f g� <br /> 3.Malling address(if diffemnt): �'Q,j�l hi __ <br /> 4.Residential addmss a[the Ume of the incident(If dHferent fmm arrent address): <br /> 50.Yne' - — <br /> 5.Claimant's telephone number. 7zS'ZcSL•67DQ <br /> � �,�� ypme Cel! &r9ness <br /> 6.Claimant'se-mailaddress: �1i�1_je��5�''�VYIUIDOCS•Q('� <br /> �1 " J <br /> INCIDENT lNFORMl�2ION: <br /> 7.Date of fncident: __�j ��3 Time: �� �0 ❑o.m. L�J p.m. (check one) <br /> (mm/ddl ) <br /> 8.If the inddent accurrecl wer a pedod of 6me,date of flrs[and last ocarrences: <br /> 6om: Tlme:_ ❑o.m. 0 p.m.(checkony ro Tlme: ❑a.m. 0 p.m.(checkone) <br /> (�iryANyvVyJ � (mmPod/m'v) <br /> 9.Lucatlon of InddenC wn'�QOYlQY1J.47J1-f—��P'�� — -L`/��� <br /> SMk dnd munty Gty,/lapp'lvb/e FYaa�err oauned <br /> 10.If the incident occurrez!on a street or highway: <br /> Namc datrecl n h/p1 xey Af Ne N�d,seMm MftA BnNresf MrRv1e[Cnp.lDPei <br /> Rw.07108 <br /> � 3 <br />