630 MAULSBY LN 2022-05-25 - Laserfiche WebLink

c)\ City of Everett Use Only RECEIVEDLIJ TORT CLAIM FORM Z z- SEP242013 Rev.07/09 - Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETT this form is for filing a tort claim against the City of Everett. Some of at-3r 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 Cleric Claim No. designated agent for the purpose of receiving claims. Claim forms pat)t) - 7 cannot be submitted electronically(via e-mail or fax). 7- O 4' PLEASETYPE OR PRINT CM EARLYIN 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: Flat Middle Date o birth l' Lstname m/dd/yyyy) a � p, 2.Current residential address: JQ (S L e re t t 1 1 "t g 1 3,Mailing address(if different): 4.Residential address at the time of the incident(if different from current address): 5.Claimant's telephone number: 42S- 51- O' ) -737r-q66 to N Business 6. Claimant's e-mail address: 615G4e-fe I10+61.xi GCSei INCIDENT INFORMATION: 7. Date of incident: DES 9i i�J'` Time:' tit +' ❑a.m. Z1 p.m. (check one) (m /dd/! ) 8.If the incident occurred over a period of time,date of first and last occurrences: from: Time: O a.m. El p.m.(check one) to Time: 0 a.m. 0 p.m.(check one) (mm/dd/yyyy) • (mm/dd/Yyyy) 'A 1 a�; 9. Location of incident: >` � d �s %/�re f- 4g0 Newt(sb take- State and county City,If applicable=: Place where occurred 10.If the incident occurred on a street or highway: 114C0415 IA Name of t or highway At the Intersection with or nearest Intersecting streeet Rev.07i09