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4L <br />TORT CLAIM FORM <br />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 be submitted electronically (via e-mail orfax). <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 />Lastname <br />SEP 0 6 2013 <br />CITY OF EVERETT <br />Cfiy Clerk <br />City Clerk Claim No. <br />210Z `-- 13 <br />Office of the City Clerk <br />City of Everett <br />2930 Wetmore Ave., Ste,1-A <br />Everett, WA 98201 <br />10'2hn �E g2r::SP.X t <br />Arst M/ddle <br />Date ofb1tth (mm/dd/yyyy) <br />2. Current residential address: 25512G> R�OAAV iVO t"t • 5VUett W ft a��,�E2O3 fin„ <br />3. Mailing address (if different): 2J-4 F5e) t-PVi rnh},�' fl(�Vi1P- tc' <br />4. Residential address at the time of the incident (if different from current address): <br />S. Claimant's telephone number: <br />6. Claimant's e-mail address: <br />Via - j,,la q-- 6`I6 <br />Cell Business <br />7. Date of incident: �312r1 �Zrsi Time: Zg: Moion ❑ a.m. Kp.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: 0 a.m. 0 p.m. (check one) to Time: 0 a.m. 0 p.m. (check one) <br />(mm/awyyyy) <br />9. Location of incident: <br />(mm/dd/yyyy) <br />Stateandiounty City, ifappAcable rS ...91ace&-3- r ur ' IBC <br />10. If the incident occurred on a street or highway:{'/► KW. ??P�c��� Z4 <br />{,t 102 <br />Name ofsfreetor highway At the intersectlon Wffi ornearest li7kvswdngstreet <br />Rev. 07109 <br />0 <br />