Laserfiche WebLink
. . . . ... .. ._.. <br />TORT CCAIM FORM <br />qav.07/09 . <br />Pursuant� to Chaptcr A.96 oF the Revlsed Coda oF Washing[an (RCW), <br />thls form Is for flling a rok ctalm agalnst tho Qry of EvcreK, Some of <br />the hifoimallon requested on thls form Is requlred hy R(W h.96.020 <br />and may be subJed to puhlir. Alsdosurc. The Gly Clerk Is tha Clty's <br />deslgnatecl a,ryenf for the purpose of recelvin9 dalms. Clalm lams <br />cannotbesuGm/Nodoloctronlcal/y(viae-nrnl/orlax). ! <br />sEP �. i �au�� . . � <br />CI'�Y OF E'VEii <br />Clty CaM'�!: <br />Cily qeik C�RM �b. <br />�� �•�.' ��J <br />�I,�lf���.'�Cr��. .�l��ei�.t����1�"��3��.���'iJ����"�:rJ'�i,Y�� <br />Mall ar deliver oitginnl sl0ned clalnl 4orni to: <br />Buslnass Nours: <br />Mon. – Prl., 8 a.ni. to B p�m�, Pacitic Tlino <br />Closed on dty holldnys <br />C,�L IMl1NTJNFORMATIOJ.�: <br />1. Gaimant's name: � <br />2, C�urcnt residentlal address: <br />OHico of the City Clerk <br />Clry o► EveruK <br />2930 Wetmoro Avo., 6to,1-rt <br />Evcrett, WA 96201 � <br />3. Melling oddress (If dlHerent): – <br />M1Jtesldentlal address et the Umo of the Inddent Qf dlRe�ent (rom current addivss): <br />5. Ualman['s tclephone numUer: '� w'` �2 '��? �–�3`��—r� ���'r � �� �Q t 5`1 _--_- <br />o c Q11 9osMess <br />6. Clalmant's c•mall addre55; �� cS'.��' �? ���a.oll, car�� - -- <br />�[JCCpGNTiNFORMATION: <br />'/. Dale ot Incldanf: � '`-'�r "�01 � <br />(miNdJIVYri) <br />T1mo ; (n' 6(j ❑ a,�m C�1 p.m, (check onr.) <br />n, if the IndJenl otttrtred aver �S per d oF lime, da[e of flrst and last ncwrrencesI� <br />p'.�lJ a.m� p.m. (diock ane) lo C(3 '���fl�c: Z/'_"-� � n.m. �R p.m. (ehcck oncl <br />Prom:6�e�/�.�Tmn, ` (mMeu/m'v) <br />(mm1AJlYV11') � . <br />(.l_) Q �_SL�!1_n._1J] � S� � l,A ;i=�. 1"�L4�_ '�i_L ���itL�.Q.L 6m.� <br />9. Locatlon of Incidenl: q/�pl,'raG/c `� � l,nor. �vhcn omurrA <br />Starcanemwrty N. <br />lo. ]f the huident oaurred on a slreet or hlghway: <br />M1amr. olshml orhl�h�ry <br />�J AtlAelnlcn.�cMonivlNa�nr»mrthrlcrsKf/n7s6rN � <br />�. Pnv.071�8 <br />