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� <br />a�..o�io9 <br />iORT CLAIM FORM <br />Vursuant lo C7iapler 4.96 of lhc Hevised Code oF VJashington (RCW), <br />thls form Is for lil6ig a tort dalm against lhc City of Everclf. Somc o( <br />lhe In(oimation requested on this form Is requlred by RCVd 9.96.020 <br />and may be subJec[ lo publir. dlsdosme. Ttie Cily Clerk Is lhc City's <br />designaled agent tor [he purpose o( recelvin� clalms. Clalm /o�ms <br />cannot ba submitted e%ctronlcully (vla e•ma!/ or /.ixJ. <br />.�\P���� V I�� <br />SEP o 9 2013 <br />Ck'�'Y OF fiVERE'd'T <br />Cli9 Cie�lc <br />Cly Clmk Ciabn No. <br />710�� � 13 <br />�PLEASETYPE-OR�PRiNTCLEARLY.�'ININKr '. . _ , , - ; :;.�..= 1 .�_... �. '-if '�.. '_`;I <br />Mall or dclfvcr original signed claim ►arm to: <br />Business Hours: <br />Man. — Fri., 6 a.m. to 5 p.m., Par.ifit Time <br />Closed on city holldays <br />CLAIDIANT INFORMATION: <br />Office of tho City Clerk <br />City oT Everett <br />2930 Wetmore Ave., Ste. 1-A <br />EveroK, WA 98201 <br />t. Clalmant's name: <br />5,v .ere s S,q-r_A. M. �� —b y-��',�_� <br />[vsfnamc firsf M/ddle Pahofbldh(mrq/dd/yy}y) <br />2.Nrrentresicentlaladdress: __.350� wv%`M0�2�. A(/'G ��(�el2e�l.1,q.. �K.�o/ <br />3. I4alling address (If dlfferent): _,,�� <br />9. ResldeNlal address al the time of the Incidrnt (i( dl(ferent from curmnt adAms,): <br />_S�M-�- _ <br />5. Clalman!5 telephone nwnbcr. _ ����• s ��-�'sya �%dJ '.3�����n <br />llomc Crll [+usincsr <br />G.ClalinanCsrmailadAics,: _SS�N_Lj_GRD✓C @_ �QL� CsM — <br />)NCiDENTINFORMATION: <br />7. Date of InddenL• . (,7R�=,.� cl _� Q[j 7ime :�� �7 ❑ a.m. 1�Q p.m. (check one) <br />(nuNdd/»ri) <br />8. If lhe Inddent occvned over a pedod of Ume, dale of IirsL and las[ occurrr.nres: ,�/ <br />hom: __ __ Time: . _ IJ a,m. 0 p.m. (check one) to lLne: �, 0 a.m. [] p.m. (check ane) <br />(mm/dA/V1'IY) (m�NJd/YriY) . <br />i <br />9. �ocatlon of Incldent: �!�" 5N f7 �✓ e1'��-�dc.e�_-� ° a- �'-° <br />Stofe an�mun(y -�^ Uty, /l appl/cu .c Pfam whcrc onvrred <br />10. If the Incident ocaured an a slreet or hlghway: /1//j9 <br />Ranre a/sircet ar/rfghwdy At fhc infcrstttlon Itvfh ornn�2st /n;crsttling rinrl <br />Rev.07/o9 <br />