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l <br /> ,.. ._ <br /> . , city of Everett9sii only 1 ; .• <br /> .oivestatil,r_erzs <br /> '7 i - TORT CLAIM FORM RECEIVED <br /> • <br /> -.--N,owi <br /> Rev.07/09t, 11 SEP 0 3 2013 • .. <br /> , <br /> ' Pursuant to Chapter 4.95 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 - <br /> the information requested on this form Is required by RCW 4,96,020 . ail cle* .., I.-.. <br /> and may be subject to public disclosure.. The City Clerk.is the:City's . .-eityoterk-olign:i•Ril.'' <br /> designated agent for the purpose of receiving claird. Claim forms POI-Li- 13 .: <br /> cannOtheiubmitted electronically(via e-mail or fax). <br /> Mail or daliVeroriginalsignediclako form.tm Office of the City Clerk <br /> City of Everett <br /> Business Hours: 2930 Wetmore Ave.,Ste. 1-A <br /> Mon.-eitcfraintito Pacific Everett,:WA 9820.1. <br /> Closed on city:tiolidays <br /> . . <br /> .. • . .CLAIMANT INFORMATION: - s <br /> 1. Claimant's name: <br /> .leu.e.,..t}-_: AQ‘s.1-.0y.k. ,:_Y-Iskyvoo.ertut TIAL oe;jc?r/BIFI/F1) <br /> ZAit mina - - ' ' • ---- -Rat -1' '-- - - Widiiik . -- ' - • tiatirtiii66im-A-flyyjiy:-T <br /> 2.Current residential address:, . Lig ri.A, etre,A.A. AAR_ t eziteet , <br /> 3. Mailing address(if different):.. . .. <br /> 4. Residential address at the tithe of the incident(if'different from current address); <br /> 5.Clairnanes'telephone nOmber: LigS- P 1 . ,9-P_Lc, 9s---.... Eiti:7-77142 <br /> tiosma <br /> 6.Claimants.e-mail address: V-4117344, 1-• .\,,, s1:,,,,e yx.1.4.1 . cor. . .. :,__. - - --- --... <br /> Xffc4pENT:INFORMATION: <br /> 7i Date ofiincident:DE-7491.). IASI)il me: 71:',:()0e::.,.- -.,El a.m. Wp.m. (check one <br /> l Ti ) 5 <br /> '.1 <br /> ( 'cid/YYVY) <br /> 8.If the Iticident.bccurred over a period of time,date of first and last occurrences; <br /> from. 7—• ,.Time:. 0 a.m. D p.m.(check°nay to. 'rime: 0 a.m. 0 p.m.(check on ) <br /> : <br /> ; <br /> (nwrifddtyyyy) kin/ad/W )' <br /> 9.Location orincident: 0 4s6c1-01N.5ie.,, oNzoAts 1,,.CD ,, . q.r„.1. .el MAC( tive_ ., ,-r......,. <br /> state and co nty - City;itappfreibk Plac. hied <br /> 10.If the incident occurred on a street or highway: • _ <br /> Nicole datieetz Or highwayAt the Intersection with or nearest intersecko street —." <br />