7318 EVERGREEN WAY 2022-05-24 - Laserfiche WebLink

• City,of Everett Use Only • n' TORT CLAIM FORM ftev.07/09 OCT 03 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), FTT 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 ` city ileric and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim"Nb.J designated agent for the purpose of receiving claims. Claim forms — cannot tie submitted electronically(via email or fax) 6-CA0130°4PS)1 , PLEASE TYPE.OR;PRINT CLEARLY IN.INK Mail or deliver original signed claim form to: Office of the City Cleric 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 l firsts Middle Date orblrth(mm/dd/yyyy) 2. Current residential address: io'l Q t /L giv rn eff � %2 3.Mailing address(if different): 4. Residential address at the time of the incident(if different from current address): LI 5. Claimant's telephone number:0786 81l9? 4R5-`567 9 9 a ,3- 7 -7&c Norg 6. Claimant's e-mail address: null c etv / T_ )-je el Business INCIDENT INFORMATIION �J 7. Date of incident D 217''v?i//3 Time: 5 36l 0 a.m., '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. 0 p.m.(check one) to Time: 0 a.m. 0 p.m.(check one). (mm/dd/yyyy) '�r�t/ ��//u$� ff (mm/dd/yyyy) 9.Location of incident: Uu/4v J l' Yr C T State and county City,If applicable Place where occurred 10.If the incident occurred on a street or highway:, 731 g &y&r -ree Name of styet or highway At the intersection►i h or nearest Intersecting street Rev.07109 ///2