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/_ �-�I <br />�� <br />� <br />Rev.07/09 <br />TORT CLAIM FORM <br />Pursuant to Chapter 4.96 oF the Revised Code of WashingMn (RCW), <br />thls form Is for 011ny a tort dalm agalnst the qty of [verett. Some of <br />lhe Informa[lon requestetl an this form Is requlred by RCW 4.96.020 <br />and may 6e subject to puhiic disclosure. The City Clerk Is the City's <br />desl9nated agent for the purpose of recelving cialms. Cla/m fornrs <br />c�nnotbe submitted e/actronira//y (via e-mai/orlax). <br />���1�� V .I�� <br />Ck'�'Y �L�F E'��f��T'1' <br />Clt�+ CICCk <br />Clly Clerk Clalm Na � <br />fil�`�-�� <br />/_' n sn� �nr� �I SN �O <br />... .:. . , . <br />PCEASET,Y.QE;ORPRINT:CLEARLY IN�INK.,-��. : •;. , ` --�"� �� -� � �"' <br />Mail or deI(ver ariginal signed clafm forr.: toi <br />Business Hours: <br />f9on. — Fri., 8 a.m. to 5 p.m., Pacific Time <br />Closed on cfty holidays <br />CLAIMANTINFORN:ATION: <br />1. Clalmant's namc: <br />���ac�'. <br />[astname <br />'l.. Current residenlial adAress: <br />3. Malling address (If different): <br />Office of the City Clerk <br />City of Euerett <br />2930 Wetmore Ave., Ste. 1-A <br />Everett� WA 9A201 <br />TJ��, � <br />HnY MiJd <br />Ol� 33r� ST L-�r�r�t <br />4. Residentlal address at the time af the Incident pf dlfferent from current addrnss): <br />5. Clalmant's te(ephone numher: <br />6. Clalmant's e-mall address: <br />INCIDENTINFORMpTION: <br />7. Date of Incldent: ��Z��L_2U 1J Time : �`� W <br />(mmldd/YYYV) <br />8. [f the Incldent occurred over a period of tlme, date of flrst and last oaurrences: <br />hom: Tlme: ❑ a.m. I] p.m. (chedc one) to llme: <br />(mm/dd/yyyy) . � � (mm/dd/yyyy).� <br />9. Lowtlon oF Inddent: <br />(.if✓� <br />10. If the Inddent occurred on a sheet or highway: <br />Businc.s <br />❑ a.m. LWp.m. (check one) <br />fl a.m. I7 p.m. (check ono) <br />� 3?�rc� �7 <br />Plare where accvrrnl <br />Name o/shnet or h+yhway At Nm inlersec�ai ivr[h ornrarest /n(ascrAnps(me! <br />Rav. OiIOB <br />