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� R�����`��L�
<br /> ` � TORT CLAIM FORM'
<br /> SEP o 5 2013
<br /> Rev.W/09
<br /> Pursuant to Chap[er 4.9G of thc Revfsed Code of Washlnylcn (RCVJ), �YTY OF EVE�tETT �
<br /> this (orm is far Oling a tort clalm against the City of Everett Some ef ei{K C�Ci•k
<br /> the in(armalion reyuested on lhis form Is requircd by R�A' 4.96.020 `J
<br /> and may be subJect to pubiic disclosure. The f,ity Cleik is the City's c�ycicrkcaMNo:
<br /> designated uger t for the purpose of receiving dalrr,s. [lalm forms �1(`(.1 � ,- I j
<br /> cannof be sub mi[ted e%cbunicalty(via e-ma!l orlaxJ. !�� • _ ,_.
<br /> PLEAS�'7Y4E,OR P�tINT CLEA�lLY;IN,INK - . ' . , ,
<br /> �
<br /> Mail or deliver original signed claim form to: OHice of the City Cicrk �,
<br /> City oi Everett i
<br /> Business Hours: 2930 Wetmore Ave.,Ste� 1-A '�
<br /> Mon.-FH.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201
<br /> Ciosed on city holldays
<br /> CLAIMANT INFORMATION: .
<br /> 1.Claimant's name: I ,
<br /> � i �
<br /> I.�� l ;) .. /�' .�/ '; ..lt,li'� 1a�. 1�l1��•:i�
<br /> .:)'i..�.i�iYl'� r'� -C�..� ' �/ G .,i '� 'r i:.
<br /> lasY name � � � � �Ysf A)idd/e� �T - Dafe o(b;Rli(mm/dd/yfyy)
<br /> 7..Nrrent residential address: , �/ i , �! �'I ,�I. ' ) j'� ., ` � �j (�; c.?�/'!' 1 �y.U J �j C/y��:. � J
<br /> l � ! i� r r` f: , / � i � , � � l�,
<br /> 3.Plalling address(If differen[): : �'.r J.e ii,t . _
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<br /> 4.Resfdential address at ihc time of thc in�ident(If different from current adAress):
<br /> �'�./ :q, .�
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<br /> .. ` ---� �—__
<br /> ; '.1,� .� ,) .�,:i,;)..;%(:';�}: "�' ', 1 �— ;1' r :, ,
<br /> 5.Claimanl s telephone number: !�.'. , ..� � ,; ; i l;'i J _
<br /> - ' � � Nnnr� ,�� � r:,' + 1 :[e(l � Business �
<br /> G.Gaimant's rmail address: !� ti. , d Y % ;ji ?. .P� � � ! �" F, . t ''1 i i��
<br /> . _ '—t=-'-•--- - -- - ----
<br /> �NCID��INFORMATION: I
<br /> :1 '-� ( '��-,•1�� f� .�rl) ❑ a.m �p.m. (checkone)
<br /> 7.Datc of inddent;.:r 1 <•::.r,(.+.'f % .j 'Tme: : r_
<br /> (mmJdd/VYYY) ....
<br /> 6.1f the Inddent aarred over a perlod of qme, date of first and IasC occurrences:
<br /> from:. � Time: .U a.m, �p.m.(d�eck one; to Tlme:____.__I]a.m. C1 p.m.(check one� ,
<br /> (mrcVJd/rvrv) � , �) (mm%dd1VVYY)� ; �! :.�. �� ) , � / ��
<br /> i 1,-' � ,�'� t C� )� L'/._ � { 1 � L ..i� ��! � 71/����/ -� i � �.:.
<br /> 9.Loeation of Ineident:I f ;' 1� r�! i� :i e�1,'-�l �r /`•. f I`� i� � �y.� � l�l���yIl_, l�. �.�.���:{� ��i.i... �
<br /> 1 ).�i� �Ei -i__. +1
<br /> Sfvfe and counry% i Gry;ilapplrcable l Placr where oceurnd
<br /> 10. If the incldent occurred on a street or high�vay:
<br /> llame efsh�t oi h-yhway A(tlrelnfcrsectrbn inth or nc�msf lntern7rng srrt�et
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