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������� <br /> TORT CUiIM FORM OCT 31 2013 <br /> "<".°'�°' �:1TY OF CV�$dBTT <br /> Piuwant to �apter 4.96 of lhe Revlmd Cade of Wasfiing[on(:QN), (�'�}N��� <br /> thls form Is for flling a tort dalm agalnst the dty of Everett. Some of °J <br /> the Inftxmatlon requested on thls farm Is mqulred try R(.Y✓ 4.96.020 <br /> and may be subJect ro public dlsdosure. The (7ty tlalc Is the dtys CiyClerkCJalm No. <br /> deslgnaled agent for the purpose of recdNng dalms, da/m innns ����� — I� <br /> rannot be subm/Ked e%ttronl�ally(v!a e-ma//orlax). <br /> � on b� <br /> ,PLEASETYPE;OR!PRINTCL�ARL�`�NiNK. .::��'�.. . . . .. _ ,. . , . '.`_" . .� . .=:'��I <br /> Mell or deliver origlnal aigned clalm form to: OHlte of the City Clcrk <br /> City o/Everett <br /> Business Nours: 2930 Wetmare Avo.,Ste.1-A <br /> Mon.—Fri.,8 a.m.to S p.m.,Vacitic Time EyeruM,WA 98201 <br /> Closed on dty holidays <br /> � CLAiMANTINFORMATiON: <br /> 1.Clalmant's name: YV�Afi� �. ��4.}Q.�� S-1�° —`('7 <br /> �rn��.G,�.Q I V . Co luw�l _ �' y - `�� <br /> [ast name � Hrst Mlddle 4�te o�b/rHi(mm/Jd/yyyy) <br /> 2.CurrentmsldenUaladdress: In �q wOt,�(`Q.In�f��—�1C���_��� <br /> 3.Malling addreu QFdifferent): �iOL�MrQ� ,__ <br /> 4.ResldenUal address at the Umc aF the RxJdent(If diffcient fmm cvrtent dddress): <br /> gam�0 <br /> �y�st�e. <br /> S.CIaImanCstelephonenumber. YaS-aSa.-�f.R,Q9 �/�S•327-J8(o$ <br /> Hane Cell Rus/nc� <br /> G.Clalmant's e•mall address: 1v�'v� �S' 14��Nnai�� •Cay+i <br /> � e r trvFOKroar[oN: �QrJ9 co1 we..�1@�.�.vnx\\ ,cam <br /> o.PP^'�' <br /> 7, Date of Inddent, �� ,d{�� iime: ��(�� O a.m. �p.m, (check one) <br /> (m 'd/WY19 _ �1 �.}� v�o-�.GI,� <br /> �70� 11�C=��`Q-ft'��'7— <br /> fl.If thc Inddent otarred over a�edod of tlm,e/date of Orst and last oaurrences:'� _ �/ <br /> (rom: Tlme: rX� 0 a.m. {Ap.m.(chede one) to� Time: ❑a.m.�pfn.(fieck one) <br /> ( Md ] (n�Nad/wW� �t�l �1�f'(�fl <br /> 9.Lowtlon ot Inddenh �,JJ��prl�lulM�C 1..� `1 " �JJQ. (1 U�"c' .�1fL1le.� <br /> 57atc a d munry ,I/appllraWc F/arn whcm awrrzd <br /> f0. if the Inddent oaurred on a street or hlghway: <br /> n/a, <br /> NemeWsriret orhqhway A!Mc/nMiserd'on w4fh oineamst/nkrser!/ng street <br /> Rev.07f09 <br /> ��r� <br />