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City of Everett Use Only <br /> "1:—A <br /> RECEIVED <br /> 4digi TORT CLAIM FORM <br /> SEP 0 5 2013 <br /> Rev,07/09 <br /> Pursuant to Chapter 4.96 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 ��ty Clerk' <br /> the Information requested on this form is required by RCW 4.96.020 <br /> and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No, <br /> designated agent for the purpose of receiving claims. Claim forms Lf ( - <br /> cannot be submitted electronically(via email or fax). <br /> r:<n., �•,,: �_� _ rs`__ �<xT-�Fc7"';z:3%i{:?os_-i�r..,..n^ *'(?,,fi;:-t13� ^^;•:,sv*�;�.�:ie:SA+"�."i`r�;�{��.v:,c-.,;y-.? <br /> s t �y a pr([+<:-::'�'x.. _ .VF -,�tt`=�a'..�n+:,u :i2trS, •.'t,� ,,:,c.:�l�✓.1E"ti"?*K�r <r�e,'v�'gsf :idl'j`>41ad`sy.'..,`.-; <br /> F-LT;�k�� �:..f� sr.6��7.{i,yn.��!T�iE:4l�La'n!;f'.'?c=ti'.":r;.?;S�„!�y„is-rYi�sJR'�:rR��litr..�Gkis�•?.T�h7.��•...'v�;fFa>xus��.Su:Y.....:'k.... ;1i,1:.��r�..}..','S,•(s..•.,n..n1�.p.h;,i•s t;7 <br /> Mail or deliver original signed claim form to: Office of the City Clerk <br /> City of Everett <br /> Business Hours: 2930 Wetmore Ave.,Ste. 1-A <br /> Mon.—Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 <br /> Closed on city holidays <br /> CLAIMANT INFORMATION: <br /> 1.Claimant's name: P446 <br /> eel Idet <br /> Last name First Middle Date of birth(nrn dd/yyyy) <br /> 2.Current residential address: 27%55 beupa44- fue"') CJere,44" 4$2d <br /> 3. Mailing address(If different): tom '6 pol 1O.t( tai''3Soli <br /> 4.Residential address at the time of the incident(If different from current address): <br /> 5. Claimant's telephone number: 41s'qss vi4e) 40.1S%•2A4G <br /> (1y� $L te .O.4• 1'ivtk• Y1 y, Cell Business <br /> 6. Claimant's a-mail address: �1 <br /> INCIDENT INFORMATION: <br /> 7.Date of incident: P3 ill/11013 Time: Nat-Sine. 0 a.m. DA p.m. (check one) <br /> (mm/dd/yyyy) <br /> 8.If the Incident occurred over a period of time,date of first and last occurrences: <br /> from:oe(2$t 1013 Time: {' n a.m. 51.p.m.(check one) tote/b lab Time:Pat'Swit lat a.m. n p.m.(check one) <br /> (mm/dd/yyyy) (mm/dd/yyyy) (,, <br /> 9. Location of incident: lJt 'S�.ii'tby1 I Sno dh ewe* .e or` t . <br /> State and county C)ty,If applicable Place where occurred <br /> 10.If the incident occurred on a street or highway: <br /> NIA- <br /> Name of street or highway At the Intersection with or nearestlntersecting street <br /> Rev.07109 <br />