1902 LOMBARD AVE 2022-05-25 - Laserfiche WebLink

#11:1A T®RT CLAIM FORMRECETVtD *Ge SEP o 3 2013 Rev.07/09 CI Y Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), * OF EVERETT this form Is for filing a tort claim against the City of Everett. Some of City Clerk the information requested on this form is required by RCW 4.96.020 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 cannot be submitted electronically(via email or fax). . PLEASE i(P,.,E,;O.i PRINT CW71;LY IN INK ..; ': .. Mail 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 INFORMATION: 1. Claimant's name: p 41. 1 t i M. O4 f 2Wt 199 Last name • First Middle Date of birth(mm/dd/yyyy) 2. Current residential address: 1702 Lombard Aire- Everett; W 90101 3. Mailing address(if different): & ) 4. Residential address at the time of the incident(if different from current address): Gli-frt4 5. Claimant's telephone number: • C°210 m0-404 2310 42.c- 342-4343 l/igne Cell Business 6. Claimant's e-mail address: nclLtpieswgrnitil• &nit • XNCIDENT INFORMATION: 7. Date of incident: . o /2_ / 2-0)3 Time : 6:50 0 a.m. It 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. ❑p.m,(check one) to Time: ❑a.m. ❑p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: W Snohow k ie.0 eas-U )t of how__ ca 1.742 to nix State and county City,(applicable Place where occurred Ave } 10.If the incident occurred on a street or highway: Lonvbard Ave, Name of street or highway At the intersection with or nearest intersecting street Rev.07109