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'I�►��. <br />`�' <br />r.ov. or/as <br />TORT CLAIM Fl�RM <br />Pursuant to Chapter 4.9G of thc Revl�ed Code of Washing[on (n�w�, <br />Uils form Is for Oling a tod clalm a9�lnst ihn Qry of Evcrett Somn of <br />the Informatlon reyuested on thls foim Is requlred by RCW 4.96.020 <br />and may be subJed lo publlc dlsdosm•e. Tho cIN Clerk Is the Ciry's <br />deslgnated agent for Nw purpose of remiving dahns, Clalm /orms <br />cannot bo subn�ltted olactronlcafJy (v!v e-mo!! or lAx). <br />Mnll ardellvcroiiginal slgnad clalm Potm to: <br />Buslnasa Houns: <br />Mon.—Frl., 8 a.m� to5 p�m„ PaclficTlmo <br />Closed an city holldaye <br />sl jMANTINPO�IMAT[0�: � <br />1, dahnant's name: � � � , <br />7., Current residenUal address: <br />3. t4alling address (If dlHercnt); <br />Oflice ot tho City Clark <br />Clty of pverett <br />2930 WehflOYe AVe.� StO� 1•A <br />Everett, WA 98201 <br />4, Hesidenllal address nt lhe tlme of Ihe lacldent (If diiTerent hom cufmnt dddress): <br />10- ��• <br />8�0 <br />5. Galmant's lcleplioiie num0el': l��� -„�r�-"��:�� ~�� �'(t'^� C/ r� - <br />1lonte ��� H��� <br />G. ClaimnnPs c•mall addresc: <br />��1 CID EN7 INFO RM ISlIQi�: <br />Date of Incidon4 l� • U�--"�U �.j <br />(mm/aIAYVYI <br />Tlmc : y�'�~� a��n. � h•m. (check onn) <br />fl.Iflhelncict nloaurrr.dov�r>>�ofUme,daleo(Ilistandlastpccurrnnceh� a_� �\� �n. checkone) <br />p�a0/'3Ti�ne: • �.io.Op.in.(checkone)ro���'��•�D a:y.2__— V� � <br />from: �' . .....---.. <br />(mMJ01WW) <br />9, Inu'illon of Incidant: <br />10,1f lhe Inddenl oocuued on a street or hlghway: <br />Namc o/shret orl+'ghway ��t Nc InlcrsM/on...�.5 ornnrm<tln�mntlwsbml <br />RoV. 07109 ' <br />Y11 <br />