4711 ELM ST 2022-05-24 - Laserfiche WebLink

, City of Everett Use Only i! ECEIVED 0111111A . 41;71 rr TORT CLAIM FORM n r Rev.07/09 CJEP - 7 2U' Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETT this form is for filing a tort claim against the City of Everett. Some of the information requested on this form is required by RCW 4.96.020 riff Clerk and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim'No. designated agent for the purpose of receiving claims. Claim forms .7 id 61 -- ''3 cannot be submitted a%tronically(via email or fax). Cre0.41.3o04/5t t PLEASE r/PE Ri P tYNT CI EARLY;_INIiyK. t,, , t Mail or deliver original signed claim form to: Office of the City Clerk • City of Everett • Business Hours: 2930 Wetmore Ave.,Ste.1-A Mon.—Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 Closed on city holidays • CLAIMANT INFORMATION: 1. Claimant's name: • Last name First Middle Date of birth(mm/dd/yyyy) 2. Current residential address: 471 ELM SA": • 3.Mailing address(if different): . 4. Residential address at the time of the incident(if different from current address): i 5. Claimant's telephone number: ( -26) 7cZ'--OL C4255Z57• 7307 Home Cell ' Bws'/ness 6. Claimant's e-mail address: 1%5---pool Com.rous • 1 leti if INCIDENT INFORMATION: ram, 7. Date of incident: A L4,,G(Asr 7..0 `7...-Cl3 Time: 1p . VCR ❑a.m. 1'p.m. (check one) (mm/dd/yyyy) 8.If the incident occurred over a period of time,date of first and last occurrences: . from: Time: 0 a.m. ❑p.m.(check one) to Time: ❑a.m. p.m.(check one) (mm/dd/yyyy) ' t (mm/dd/yyyy) 1(U 9. Location of incident: P&�1.NO i /Wo WYK.{ ,P Y .-0, (i 471 i h1M. S State and county City,Ifapplicable Pace where occurred 10.If the incident occurred on a street or highway: et—NA (. A ' / 1-� 1.-v`A • Name of street or highway At the intersection with or nearest intersecting street Rev.07i09