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<br /> `: .. '� . ' TORT CLAIM FORM � i
<br /> ' , 'AUG 3 0 7oi3 •
<br /> ne�.wros ' . I *�/
<br /> P�rsuant to Chaptcr 4.96 of the Revised Code of 1Nashinglon (R�)� �xl'I 0��Vl%l��'� ' ' � I
<br /> Uii,fom i5 for filing a tort claim agalnst the City o(Evemtt: Some oF . C�� CIC'lY4 ' �
<br /> lhe inPormatron reruested on thls fortn Is requircd by RC1Y 9.96.020
<br /> ,`.....,- _ .
<br /> and may be su6jeR [o publlt dlsclosure. 'fhe City Cierk.is the Ciry's c�ryar,E G,,�No:• � � .
<br /> deslgnatetl agen[ for the purpose of recelJing claims, C/s/m/orms ` I\ n�n� y I�
<br /> canno[be subreiked e%iro»lcal/y(v/.�e•mai/or faxJ. �
<br /> '`- � - - � .:. �- . .;,, . . _,.. ...,, .
<br /> pLEA$E�TYP��.UR.PRINTCLEAR_L'1(n1IN�L�UIf`C.`!�'�� ..t �, .,.,. -�� • � �,. � � � .
<br /> Mall or tleliver oHglnal signed claim torm to: Offiea of tba City Cleric
<br /> City ot Everett � �
<br /> 8usiness Hours: 2930 Wetmore Ave.,Ste.1-A �
<br /> Man.-Fri.;8 a.m�to 5 p.m.,.PacificTime Everett,WA 98201
<br /> Clased on city holidays
<br /> CLAIr'IANT INFORMpttON: `�/ � �
<br /> �
<br /> 1.UaimanPs name: '
<br /> _ ... . C �. ...-- _..�o. ���e,��,—. IS�.VOv�h'C .,.--��0 i S �_��
<br /> last name . �. �.. . Fisi MlOdle � � Datc b/ i(mnVa�Yl ..
<br /> - �.Nrren[residenlial address:. � � �` Q.v_�;A�, C,V'�. . \�(� ��D i
<br /> 3.Ma'ling address(tf different): : ��^-C. �
<br /> ..... .. _. -,,.•—�,_. ,-_ s
<br /> 4.Rc;identlal address at the[ime o(lhe Incident(IF different from currenl ndAross): :
<br /> C
<br /> .•-- _, �-�s��.'_-._�
<br /> -- ,-.- _ .:.
<br /> 5.Cfalmanr�tClephoh:numher. �{;�S 3I,�1_, OS O , .� �
<br /> \ �/ tc•.. . . . p CeB 6usiness -.
<br /> 6,daimanPseinaflaOdrCss: v,C�Q�\y� I ^f� U�,C��M0.� �m '
<br /> �--.+.. 1 ��_ _._—r. ....
<br /> �'ICIDENTINFORMATION: /
<br /> 7. Date of inddent: .�('�y,--�{ �.`.1 �I �Time: �,0� 0 151� �]a.m. ly p.ln. (chedc on0)
<br /> (mm/dd/ ) . _ . .. . . .
<br /> B.If N�e Inddenl occuired ov�a period of Ume,date of frst anJ last occurrenc�:
<br /> from: .Timc:�___Oa.m. Op.m.(dicck�neJto Timc:___pa.m. fJp.m.(ehedcopc� '
<br /> ..(mmIJdIVYY1'�� �c.n{.. �n ��ni.V�ctu-�� (��n�i��-�{/mv) I
<br /> 9.�.aG�t�on of Inddent: �1���_�_.�?%�r��� .��^'"�a.� ��cariv �.��
<br /> SYofcenJca�n(y . Oty�Aapp'i[ab.�C P/dcBNheM.oCYunLd '
<br /> 10.If the inclAent o:cumed on a street or hlghway:
<br /> \�.r re� �i�"Q,_ __ ��},v.c�. -_S�Qc��R, b�n SWto� �,�U_-.y2 ��0
<br /> � h'amco/aheM�n•M�hw:ry � AltlrpMlencMaiwtith� cvnea�YhtaseQ/rtg.sbref
<br /> �y�� �V�f� ��lC�a,�� (� ,
<br /> "C ���o4s;, �'C�k�:,Lc. -Cw ��n.a� `�w'� W���ti. �i ��,� S�n—�..�SC��t��, �`°�� �'�c�lt
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