519 PECKS DR 2022-05-26 - Laserfiche WebLink

P A 1 < 00 ci Avr, tt City of Everett Use Only ol#411r1"Nkollk,mllii REcEivT:1D rr TORT CLAIM FORM SEP 16 2913 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 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 citys City Clerk Claim No. e7 designated agent for the purpose of receiving claims. Claim forms r,12c1 cannot be submitted electronically(via e-mail or fax). 6-C-010(.300 4535 PLEASE rreg.P13,?R.INT CLEARLY-In INK . , Mail or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste.14 Mon.—Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION: 1. Claimant's name: e, 7-.; -36 • Last name First Middle Date of birth(mm/dri)Yy) 2.Current residential address: 5AC)..5 3.Mailing address(if different): 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number /1,-A,,----36---3-,3g4,;? xi6dc- Home Cell Business 6, Claimant's e-rnail address: ‘1-1 iee gii.)-0 0 Ai INCIDENT INFORMATION: 7, Date of incident Time:6 Lig' D a.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. 0 p.m.(check one) to Time: 0 a.m. D p.m.(check one) (mm/dd/yyyy) (mm/dd/YYYY) 'TA/c.E. 751 Mee- /41 9. Location of Incident WA-51-4 "YA...)t)iJo i 606/2A-71—/alb p e)Ail OfA4e-i /4011.16 State and county City,if applicable 7Place where occurred 10. If the Incident occurred on a street or highway: (1P€ Name of street or highway At the Intersection with or nearest inte.secting street Rev.07/09 h A-142 X60 ttrAS- tb3 P oc_s; p 12-99"'us jA) IC 449 ne ge.9-i>usb ) A4, . 0,0042). /7/4A.j... ze