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. <br /> cl olEvo�ottuenonry <br /> R�CEI�IE� <br /> ,�n' TO/ZT CLAIM FORA9 SEP o 3 2013 <br /> Pev.OP/W i <br /> Parsuant to Cha�[cr 496 of the ReNsed Code of Washln9lon(RCIV), �li�Y �,t' �V�'��'.4�' <br /> thls form Is for fiting a tort ctalm agalnst Ihe qry of Everett. Some of �,'IfV CiM'�f � <br /> the Informallon requested on lhls form Is requlred by RCW A.C5.070 CIIyG�<ikCda�— <br /> and may be subjed ro publit dlsclosure. The Clty qerk Is :nc Clly'.•. � � �� � I � <br /> desl9na[ed a9ent for the purpose oF recelving dalms. Clahn fa�nrs _ <br /> eannntLesuLnri(fedelectronlcally(vJae-m:rllorf�xJ. _ ��1���y�D <br /> pL SE'it'•V".P��ORiPR�NT�.CL�'�1QI.Y;f�IN INK � ,. i � .: �.i4Y , �:.,�j.. ' ` ` ;.�, . � ;�'', , ��.`.. <br /> ��. � <br /> Mail or deltveroripinal slgned clalm form tn: Offlce of the Clty Clerk <br /> � City oP Everett <br /> Buslness Hours: 2930 Wetmore Avo.,Ste.1-A <br /> Mon.-Fri.,8 a.m.to S p.m.,Pacl!ic Time Fverett,WA 90201 <br /> Closed on city ho�idays <br /> CLASMANTINFORMATION: - . <br /> i.qaimanCs namc: <br /> �[1)�' r Ar7�'-�'.---��—l��' L 1— l 1�t 1 � / 9 4'.�i <br /> Lastlwine f7�s7 M/Jdlc Odlc olb/.h(mni/Gd/yyyy) <br /> 2.Curcent resldenual andress: U_J �.✓r�Fr»��� �Vl� <br /> 3.Malling address Qf dlffcrent): __ _ - -- <br /> A.Rcsidential address at Uic Ume of tlie Inddent(I'dlKerent Irorn currcnt address): <br /> s.clahnanCs te�epnonr,nwnber: _ `�L' • 3i��` `�3 �J <br /> � � Homc [cl/ �uslnecs <br /> G.ClalmanCs c-mall addrcss; ___.S=,N��'1L�!-�9f2��•.._4�.1,�--- � <br /> � �NCIDENTINFORMATION: <br /> 7.Date of InddenL• ._c�=.l Z'J/. L 0' Z Time : :_--_ 0�.m.�p.m. (check one; <br /> (mMA�UYI�VY) <br /> 8.if lh�6itlAent oc[uncd over a pertod o`llme,clale of first and lasl ocaun:nces: <br /> fmm: 'ilme:_._O;�.m. 0 p.m.(check one) M Tlme:___.__U a.m. I]p.m.(chttk one) <br /> (mmlddlYYYY) �mm/dA/VYYY) <br /> 2 Lvrallonof Intldent: . _ )�1/.il•�I��_ (�U l IaJ'�vy�o..� 0�!.a. <br /> Sfatc anAmunry C/N.ll��l�Plin•L.�c !$acc Wlrem aruiml . <br /> 10.I(thc InUAcnt oavrmd on a strcct or hlghway: <br /> Namc olalrref a�/lghnay Af fhe 6r(ersttlMn wqh oi nca2st lntersecfing s(mN <br /> RaV.07109 <br /> II V <br />