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No 3
<br /> _____ _, _ _
<br /> _ _______
<br /> , .
<br /> 1
<br /> RgC D • 1
<br /> -/va-
<br /> at TORT CLAIM FORM
<br /> OCT 0 1 2013
<br /> Rev,07/09 ,
<br /> Pursuant to Chapter 4,96 of the Revised code of Washington (RCW), CITY OF EVERETT
<br /> this form is for filing a tort claim against the My of Everett. Some of ,
<br /> the informatloh requested on this form is required by RCW 4,96.020 ay Cie*
<br /> and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim ?-
<br /> designated agent for the purpose of receiving claims. Claim forms 9 cig - 17-3
<br /> cannot ha submitted electronically(via e-mail or fax). Ctes.3,..0t00 q 64,0
<br /> OA_AfMPgfQl§ikgilqTta:*atdfritW:n'‘:',2.t;:-.'-'W6,-.4.'Mirl-'1-,-FL.'.,.--Z.:4;2 i'a,';:':.r."--•;:•3:°::73'.' sn_i...!:.',; ;;I: ":,-, '':',,,':"•:^
<br /> Mail or deliver original signed dein':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 Time Everett,WA 98201
<br /> Closed on city holidays
<br /> CLAIMANT INFORMATION:
<br /> 1. Claimant's name: .
<br /> L 01/41 onck Darn to_\a ---- LtrA..k._. I Co 1 1 1 tct5y-
<br /> Lastname First Middle Date of birth(moVddlyyyy)
<br /> 2. Current residential address: I 1-1 , -, c,v.i.c.--et.ler Ali L.
<br /> v otAA-- W - GI ao i
<br /> --- ), _
<br /> 1 Mailing address(if different): 0 ( 1 lt+14
<br /> 4,Residential address at the time of tgilgeritC(If iffeWfArri currenaPes9)H
<br /> ' 51 Vne_
<br /> i 1,,„..- --",,,„ .--ka i i I
<br /> 5. Claimant's telephone number: f) Ia.. ..--1,4.- --,...),,-..)1)-- 14--1 1 r) ILA_
<br /> i Home , i f-:\ , Cell liSillegg
<br /> G.Claimant's e-mail address: pa tyNeArt. \0,I Cry1_0._ ry \1 Ck„r0Cs
<br /> INCIDENi INFORMATION:._.
<br /> lu.3 1-2 —s1 i 2.0 5
<br /> 7.Date of inddent: 5 : et.),\10 ,- 0-1'N z ot. Time: 0 a.m. 0 p.m. (check one
<br /> (mmidd/YVY0 1
<br /> 8.If the incident occurred over a period of time,date of first and last occurrences:
<br /> from: lime: 0 a.m, El p.m.(check one) to Time: 0 a.m. D p.m.(check one)
<br /> (mm/dd/yyyy) (mmjcid/yyyy)
<br /> 1,k
<br /> 9. Location of incident: v3r6 ‘nai-nr) ;5rdneWlish e(rt'ec-1-1--
<br /> State and cout ' aly,If applIcdble Place where occurred
<br /> 10. If the incident occurred on a street or highway:
<br /> Name of stmetor highway At the Intersection with or nearest bee/sect/rig street
<br /> Rev.07109
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