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l <br />TORT CLAIM FORM <br />Pursuant to Chapter 4.96 of the Revised Code of Washington (RC",. <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 be submitted electronically (via email'orfax) <br />. <br />City of Everett Use Only <br />NOV 2 2 2013 <br />CITY OF EVERE T <br />PCASE,TYPE <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. I -A, <br />Mon. - Fri., 8 a.m. to 5 p.m., Pacific Titre, Everett, WA 98201 <br />Closed on city holidays <br />CLAIMANT INFORMATION. b (A-c crlavv--\ Uq "3383663q; <br />1. Claimant's name: <br />Last name FirstMiddle Da e of h/rth (m1n1dd/yyW) <br />2. Current residential address: 3G�) CGLS �- { 1( la- 'S- " •+ t O�As%p W t 2F-�.. 1s r v 14 Q-)-q D' <br />3. Mailing address (if :different):{1i�-,s-( PSI C. `fit; (�` <br />4. Residential address at the time of the incident (if different from current address);. <br />5. Cialmanes telephone number: <br />Home cell Business <br />6. Claimant's a -mail address 0--Wso n . � a f rke W p t 1 be.rV" <br />INCIDENT YNEORMATION: <br />aui <br />7. Date of incident:. Li�S-3 I- lime l9 ❑ a.m. p.m. (check one) <br />(mm/dd/Yy N)' <br />8. If the incident occurred over a period of time, date of first and last occurrences:` <br />from; Time: ❑ a.m; 0 p.m. (check one) to Time: 0a.m. ❑ p.m. (check.one) <br />(mm/dd/yyyy) (mm/dd/yyYY) <br />9. Location of incident: WA I <br />State add county CIO,, If applicable Place where occurred <br />J.O. If the incident occurred on a street or highway: <br />vNn! r\ . , A ,, <br />Rev. 07109, <br />i- A Ck:,-A 37'= <br />tersedlon with or nearest intersecting street <br />