Laserfiche WebLink
Rev. 07/09 <br />Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), <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 <br />and may be subject to public disclosure. The City Clerk is the City's <br />designated agent for the purpose of receiving claims. Claim forms <br />cannot he submitted electronically (via e-mail or fax). <br />City of Everett Use only <br />City Clerk Glaim No. <br />:.- - <br />iRl1a�E:.7YNE;OR"•_P123(i�tl"GICAitiY';NINI�';;;;;<.,,._::•.::...r.:..;. <br />Mail or deliver original signed claim form to: <br />Business Hours: <br />Mon. — Fri., 8 a.m. to 5 p.m., pacific Time <br />Closed on city holidays <br />CLAIMANT INFORMATION.' <br />1. Claimant's name: <br />office of the City Cleric <br />City of Everett <br />2930 Wetmore Ave., Ste. I -A <br />Everett, WA 98201 <br />Last name First Middle Date ofbiith (mm/dd/yyyy) <br />2. Current residential address: <br />3. Maiiing address (if different): <br />4. Residential address at the time of the incident (if different from current address): <br />5. Claimant's telephone number: <br />6. Claimant's e-mail address: <br />Home Cell Business <br />INCIDENT INFORMATION: <br />7, Date of incident: i`.� ► Time: ❑ a.m. OP. 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: Time: ❑ a.m. ❑ p.m. (check one) to Time: <br />(mm/ddlyyyy) (mm/dd/yyyy) <br />9. Location of incident: \,v <br />State and county Glty, If applicable <br />10. If the Incident <br />occurred on a street or highway: <br />Ail e. <br />Nameotsbee erhlglimby <br />❑ a.m. ❑ p.m. (check one) <br />Place where occurred <br />At the lntersetdon Wth or nearest intersecang sneer <br />Rev. 07109 <br />'P <br />