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, f F <br /> iffofr RECEIVED <br /> Fr TORT CLAIM FORM SEP 25 2013 V <br /> Rev.07/09 <br /> Pursuant to Chapter 4.96 of the Revised Code of Washington(RCW), CITY OF EVERETT <br /> this form Is for filing a tort claim against the City of Everett. Some of City.Clek <br /> the Information requested on this form is required by RCW 4,96.020 <br /> arid may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No. <br /> designated agent for the purpose of receiving claims. Claim forms r)1Afe) — 13 <br /> cannot be submitted electronically(via e-mail or fax), <br /> 662%30041 917 <br /> iim-.000.iyik.okpAnsttatiotisy-T:xpoto,-:-..-::::,-..`,:,Y.,,,K,./•::,?t;',1::.:; :z;i;yie,.:-. : 2 :.-;1.:::::,-,v,:-.,..,,,,,:.>,::-..,-.. .: :,-J.::::::.',.- <br /> Mall or deliver original signed claim form to: Office of the City Clerk <br /> City of Everett <br /> Business Hours: 2930 Wetmore Ave.,Ste.1-A <br /> Mon.—Fri.,8 a.m.to 5 p.m. PadficTime Everett,WA 98201 <br /> Closed on city holidays <br /> CLAIMANT INFORMATIOK: <br /> 1.Claimant's name: <br /> Ot...4 pm AN ITA d a 3- ( -3 <br /> Last name First Middle Date of birth(mm/dWyyw) <br /> 2.Current residential address: tq 3 I Grttn(I A ue..*to:i- 4-.:-tier P 6, 9 ?910/ <br /> 3.Mailing address(if different): <br /> A, 4.Residential address atzateekiale of the incident(If different from current addr ss): . <br /> SAC.1,Xettl,'\ OCCtArif el ck 7(a _ C bk,Oki GU ie.4\ Ls kfacciv\A <br /> 5.Claimant's telephone number: 100'-a5.3.- Itto-, Loss-.13t-vot AciA <br /> , t„ Home Cell Business <br /> 6,Claimant's e-mail address: fit (4 <br /> INCIDENT INFORMATION: <br /> 7.Date of incident: Time: 0 a.m. ap.m. (check one) <br /> (mre/dd/yyyy) <br /> 8,If the incident occurred over a period of time,date of first and last occurrences: <br /> from: --f-Jtiq`13Tilne; El a.m.jirp.m.(check one) to cf -05%13 Time: El a.m. ip,m.(check one) <br /> maVd<INYYY) (rrniddhyyy) <br /> 9.Location of incident: VJA51-11Wqrol.i I 514b110141S14fi EVCReir i I d'N COk :t1L . 4 lie 1 <br /> State end county aly,If applicable Place where owe ted <br /> 10.If the Incident occurred on a street or highway: <br /> A <br /> Nj <br /> Name of are or highway At/he Intersection with or nearest 1de/sect/op sheet <br /> Rev.07/09 <br /> / <br /> a <br /> I Sonioce oytti p itPopc.;(ko'ki 0,.1- -iia, cotcli ( cor 1 e <br /> i <br /> ct. akillous 0 oa.) c reS‘koue 9,7(4tk.c kla <br />