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� <br />� <br />TORT CLAIM FORM <br />ao..o�/a9 <br />Purswnt lo Chapter 9.96 of the Revised Cade o( Washingron (RCW), <br />this (orm Is (or Flllnq a tort daim agalnst the City of Everclt. Some of <br />[he In(ormation reques[ed on lhls form Is requlred by RCW A96.020 <br />and may be subje�t lo public discbsure. The City CJerk Is Ihe Clty's <br />designated agr.n[ for Uw purpose of rccelving dalms. C/a1m lorms <br />cannot be submiKed e%dronica!!y (via e-ma1/ ar /ax). <br />Ciry ot Everott Usn Only <br />����� r 1'.J�J <br />SEP 12 2013 <br />CITY OF EVERETT <br />�,rype�i �NClerlr <br />D I 27 - (3 <br />GCao� 3oo_y�s3 <br />' €!!9 � � R:'P,�Iiy��C+R��i �iN_A(� •,1 ��< < ,�:�,?-��:+_ ..�ti_;... , i <br />, , -, "-, G n <br />iPL E1 P�p V ..,�.� k....�.y.:i;�_... `_ ".�.:lif'd.....'u`a.�� c�17'bi <br />Mail or deliver origfnal signed claim farm to: OKce oF the City Clerk <br />City o( EveroN <br />Business Haurs: 2930 Wetmore Ave., Ste. 1-A <br />Mon.— Fri., 8 a.m. io 5 p.m., PacificTimc Evcrott, WA 98201 <br />Ciosed on city lioliclays <br />CLAiMANT �JdFORMATiQL�: <br />G�� <br />1. Clalmant's namc: �� � � � I ��'��� � `��� <br />(ust namc <br />2. Current re;idenUal address: <br />3. hlalling aJdress Qf dif(erenl): <br />M�Ad/e a�rc orn�rtn (n,m/dd%yyyy) <br />4. Residentlal address a[ the tlme of the Incident Qf dlfferent from arrent address): <br />S. Gahnant; tclephonc numbcr. <br />G. Qamiant's e-mail adAress: <br />�IDENT iNFORM�ITI.ON: <br />7. Datc o( IndJcnl: - - <br />(mmJJAIyP/y) <br />Namc - �-- Ccl/ <br />llmr.: <br />Uusiness <br />f_I am. ❑ p.m. (check one) <br />e. If Ihc Inddcid uu:urred over a perind of limc, datc of first and last occurrcn�es: <br />from: ____ ��me: CI a.m. 0 p.m. (ch ' ne) lo lime: ___ U�.m. CI p.m. (check nne) <br />(mMdd/WV'A (mmldA/YYYV) <br />9. Lo��Gon nf Inr.Wen[: _ <br />Sf��h and munry <br />10. If the InGdent occurrr.d on a sireet or hl9hway: <br />Namc olsfreef nr h/ghrvey <br />Rev. 0T109 <br />: ir�� .; aopllc.'+b/c Placc whem <br />A( 7hc /nla:c[INn wifh oi nwrrsf Nlmreflny shecf <br />