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<br /> 001113122 laza,,
<br /> 10141P Clt9 of Everett Use Orli,
<br /> RECEIVED
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<br /> :,. , ,,,. ., TORT CLAIM FORM
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<br /> _ SEP 13 2013
<br /> Rev.67/09,
<br /> Pursuant to Chapter 4.96 of the Revised Code of Washington (Rarli), . 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 City Clerk
<br /> and may be subject to public disclostire. The City Clerk is the City's city C1-6 k Claim No.: . -- —
<br /> designated agent for the purpose of receiving cialmt. Claim forms 1 f. ) - 13
<br /> cannot be submitted electronically(via e-mail or fax). 1 .
<br /> . . , _. ., . _ 6epz‘ c:?so.:1-ti-itccr
<br /> 44.0107.1101tilkiwitittolYantiogiNORA-gitiWgtta:4-;,5„ -P,'15AtithafA4:ftvgi
<br /> Mall or deliVer ciriginal'signettclaim formtig Office of the City Clerk
<br /> City of Everett •
<br /> •Business Hours: 2936 Wetmore Ave.,Ste.I-A
<br /> Mon.-FriOla.ni.tO 5•pimi:Pacific:Time Everett,WA 98291.
<br /> 'Cloged on'OltyhOlidays i.
<br /> CLAIMANT INFORMATION:
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<br /> 1:Claimant's name: ,,..
<br /> CO i .)t tieNtrA Last name rkst - 'Riddle - ' 'I 66orb7rth(iiim/dyyyy- ).
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<br /> .Current residential address , 703— "-----.` ' .. - .! • '
<br /> 3.Mailing address(if different): ;;.,_ _-, t'u•-e----
<br /> 4:Residential addresset the tithe of the incident(if different from current address):
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<br /> . _,..- A..._.-..„..4. •i
<br /> los- Is-.1 ei-ic /. i,
<br /> 5.Claimant's telephone()Umber:: ' : !,_.,t:' , Vic 3.1-1 •.DA•3
<br /> ,,, 1 lane:;i,, , i , r-z) ,,, Cell, r i Bizsifiev -
<br /> 6.Clalmantt e-mall address: 6.-t lic=-1', e1,6, !€,'IAA'r-1/1' 6:4, (7' "AVIA I
<br /> ' --- - . „_
<br /> INCIDENT INFORMATION:
<br /> 7i Date of incident: , Ei :A._.).$...._ .....„ .
<br /> "Time: ••••-(PPAN - D a.m.A:p.m. (check one)
<br /> -.......--
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<br /> (mmJcid/yyyy)
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<br /> 8.If the incident,Occurred over a.period of time, date of first and last Occurrences;
<br /> from:--• -_ - lime: 0 a.m. 0 p.m.(check one) to.. .„.. Time: 0 a,m. 0 p.m.(check ow)
<br /> Onnliddlril Orii-nfildinw).
<br /> 9.Location of incident: -44- 51-, k 4,:::-0- -,,,i,e,rr ("0 3 1 ---- t O
<br /> t.. 44.-
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<br /> State and county - -Clly;ifapplicable Place whoreocrurred
<br /> 10:lithe incident occurred on a street or highway:
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<br /> 011,iiire entreat•or 1highwayAt the Intersection with or nearest inteisecting street -
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