4724 GLENHAVEN DR 2022-05-24 - Laserfiche WebLink

r City of Everett Use Only ' .., RECEIVED • _Er, TORT CLAIM FORM SEP 1. 6 2013 Rev.07/09 . , . . Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETT this farm 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 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 ---) 138_ i cannot he submitted electronically(via o-mail or fax). 6-Caini30 04'1500 1'':'-,'': ::•:,! i`‘.,...:-.....:=1,-, ;,-;.-,-.-,„;' 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 iNFoRmAnoN: .. . . 1,Claimant's name: Sli'9 a 14 - . ., , , .. Ayyt a ndot Be-IA Olf at 17,.,7 Last name First Middle Date of birth(mm/dd/yyyy) 2.Current residential.addres: 4t71- 61erilleievt... D.g./areel-4-f 0a4 qs c.9-0. 3.Mailing address(if different): - 4.Residential address at the time of the incident(if different from current address): e as c ttiz-oef)--1-- aJciagss 5.Claimant's telephone number: --a- _ gp 6 -‘199 --ggS9 Home ., ,_.., ',(Cell Business 6.Claimant's e-mail address: a Al arlaa Si 90 I a (C...)9 mai . co . INCIDENT INFORMATION: 7,Date of incident: 0 /810-ei #.9413 lime: /, ..-7 I fin -,"'-' 0 a.m. F4.rn. (check one) (mm/dom 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/ffily)... . - , (ritn/cfd/yyyy) 9.Location of Incident: .WA ,Soohoem isii 6eg--e.11 Pes'Vence _ .. .. - - St-ate and county aly,"applicable Place where occurred 10.If the incident occurred on a street or highway:7: V - A.i. . - . Name ofstreet or highway At the Intersection with or nearestintersecting street