7318 EVERGREEN WAY 2022-05-24 - Laserfiche WebLink

, 6 tA//4 . * City of Everett Use On!. ' F023 /1(/71-ir---/- ' 11 h .r. , TORT CLAIM FORM Nlifie 03 OCT 08 2013 Rev.o7/o9 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCVV), CITY OF EVERETT this form is for filing a tort claim against the City of Everett. Some of City Clek the information requested on this form is required by RCW 4.96.020 and may be subjed to public disclosure. The City Clerk is the City's City Clerk Claim No. designated agent for the purpose of receiving claims. Claim forms c)91(;),(0 - 0 f cannot be submitted electronically(via e-mail or fax), 6620 i 3 oogsg-4, ',7115 tkitIETW tit-b.Ai. k7:13.1-LitThrikg- Mall 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: ...., ifsz..k/4/3- Last name name First Middle Date of birth(mm/dd/yyyy) 2. Current residential address: 0-t7iftff ''-- -elle IAA?' 3. Mailing address(if different): 4. Residential address at the time of the incident(if different froin current address): obl ' ? 6 486 S. Claimant's telephone number: _. 0, -1- 5 — tiome Cell Business 6. Claimant's e-mall address: INCIDENT INFORMATION: 07 66 7. Date of incident: / 013ti/iPa 0 0--- Time : a.m....,m p.m. (check one) (rrimiddjmy) 8. If the incident occurred over a period of time, date of first and last occurrences: from: Time: 0•a.m. 0 p.m. (check one) to Time: 0 a.m. 0 p.m.(check one) (mm/ddhyyy) , (mm/ddhyyy) VVA 9. Location of incident: - A '44 ,C ,-ca- 1 itfsea State and county City,if applicable Place where occurred 10. If the.incident occurred on a street or highway: Name of street or highway At the Intersection with or nearest intersecting street ,,. Rev.07109 ....