3311 PINE ST 2022-05-26 - Laserfiche WebLink

i City of Everett Use O.nly_ oroolilp„, .....- RECEIVED .41;1 TORT CLAIM FORM SEP 1. 1 2013 ReV,07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF E y ERE d this form is for filing a tort daim against the City of Everett. Some of CI. Clams- the Information requested on this form Is required by ROW 4,96,020 and may be subject to public disclosure, The City Clerk Is the City's City Cierk Claim No. designated agent for the purpose of receiving claims, Claim formspto- cannot be submitted electronically(via a-mail or fax). t 0 y - l -r`r a�ti�'7rl'E z�..a!--r at r' aM ai -'-g�{fig` MffEA 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.Ciai ant's name: l5~//q? Last name First Middle. Date of rth(mm,dd/yyyy) 2.Current residential address: 33/i P 01 11- 6-Ae "e- ` f 1,---)a 3,Mailing address(if different): 4.Residential address at the time of the incident(if different from current address): JGt`01—e. S.Claimant's telephone number: ' 3`. .Jr '14' C/ a3 77Ob 11- /OfHorre Cell Suslness 6.Claimant's e-mail address: INCIDENT INFORMATION:' 7.Date of Incident: C '/ ? / Time: r ,' 0a.m. p.m. (check one) (mm/ddJyyyy)' 8.If the Incidentttr000 urred over a period of time,date of first and lastyurrei ces: from: zz dime 0 a.n1; p.m.(check one) to( Time: f 2: a.m, p.m.`(check one) ( (mid /yyyy) ( dd y !ll• 9.Location of incident: uik.. 5nc9ht lV,/,Th cjf.—e. 33j1 orce_.57— State and county City,if applicable Place where occurred r -i` , 10.If the incident occurred oir a street or highway: Name of street or highway At the Intersection with or nearest Intersecting street Rev.07t09 qi3 l