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� . <br /> �------„ <br /> ����� � I <br /> � <br /> � TORt CLAtM FORM 'AUG ;i u 70�3 � <br /> � <br /> ne�.o��os ; <br /> Pursuant to ChaF ter 4.96 of the Revised Cade of Washin9ton (RCVJ), �^l��� �vFl���r� i <br /> this form fs tar flling a tort claim agalnst the City of Everett. Some of �'�M �'l�k I <br /> the infortna[ion requested on this form Is requit_� by RQY 4.96.020 `� <br /> and may be sub)ett to pu6lic disclosure. The City CIerY. is the Gty'S ClyGerkGalm No: - I <br /> designatcd agent for the purposr of receNfng daims. Cla/ro fvrms `�n/n� ,3 i <br /> cannot be submi[ted e%dronica/ty(Vl�e-mail or faxJ. <br /> PLEASE TYPE,OR P1tIMT;CLEARLY`IN INN�`' ; . •+ , . � <br /> Mail ar detiver original signed claim form to: Office of tha Ciry Clerk <br /> City of Everett <br /> 8usiness Hours: 2930 Wetmore Avc.,Ste. 1-A <br /> Mon.-Fri.,8 a.m.to 5 p.m.,Pacifie Time Everett,WA 98201 <br /> Closed on city holidays <br /> CLAIMANTINFORMATION: ' Vj <br /> 1.ClalmanYs name: ' I <br /> ��� • .�r�4.� r1� C �'e�� P, LS�V �� '�,_c�a � S � <br /> �-��-�- <br /> [ast name � � � Rrsf - � P'/dd/e Dafe /br (mnydJ/yyyy) , <br /> 7..Current residentlal address: �Z� � , � 'f(�v� _�V'Z• ���, , Wn �1��1_ <br /> 3.Mah'ng address(if different): �'K`�2.. <br /> 4. Residential address at lhc time of the incident Qf diffcrent from wrrent address): <br /> �vti� <br /> 5.Claii�anl's lclephone number. _ ,}S 3��1_ �D`� O _ `� <br /> I H are . . � p---' Ceq ^ Basine.:s - <br /> 6.ClaimanCse•mailaddm;s: Nf _\y�i5. � O�,C'V�10.� , ��_.�y� � <br /> 1 <br /> �IDENTINFORMATI,Qn: / <br /> J.Dale of incident: �`1 �°�j Tlme: _�,{.�O�SI, ❑a,m. I�J p.ni. (check one) <br /> nT!Ji/ ) <br /> 6.If the Incident occurred over a pericd of time, date of first and last oaurrences: <br /> from:� Time:__f]a.m. 0 p.m.(check ore) to Time:_.___,I 1 a.m. I J p.m.(check�ne) <br /> (mm/ddlw✓r'1 ���e,ea�. -�tn ��l"1C��te<..�+V. (mmjddlVYVV) <br /> 9.Loli�tion of Incident: �y>J:� `�3—�� '�•___�i i��� . C^^�u.�h' ���i'� ��Gy�y.�', <br /> 57atc and ccunty Oty,rf apfMrpt!c P/rtY wherC ocrurn,•d <br /> 10. If thc inddent acurred on a street or highway: <br /> �i.t rn`^-��----- �c1w.�R. - cr. Qc��� oY. S�ot �� t� �.o <br /> N,3me ofsircrf a h.g�5w�ry q(tlre/ntenrciiar mM or neamst NfnS.Ming s7rcYf i <br /> �J4'� �,/1 W....�� , �_�1� <br /> `�(' �Q<c� ���a.�.--�� -r��, l.0 ati 14.c�� �����L . 3 �.��> >\.i���G.�S S c��ec�, r"'-x-� .— <br /> J_. l ��� � <br />