Laserfiche WebLink
lir <br /> City of Everett Use Only <br /> e/P' RECEIVED <br /> T/ T CLAIM FORM <br /> vigi <br /> SEP 12 2Q13 <br /> Rev.07/09 <br /> Pursuant to Chapter 4.96 of the Revised Code of Washington(RCW), CITY OF EVERET <br /> this form is for filing a tart claim against the City of Everett. Some of <br /> the Information requested on this form Is required by RCW 4.96.020 Ci r Cie 'k <br /> and may be subject to public disdpsure, The City Clerk Is the City's City Clerk Claim <br /> designated agent for the purpose of receiving claims, Claim forms p i Z"t <br /> cannot be submitted electronically(via e—mail l or fax). , t 3v!" f <br /> ..w:;� m, �. ` \ 4` l� � ��%i '1 4 4`N l Cox �.. t�3S]'4't�Y�1'�C[14�� �5 l�l. \� y J�i[ 3'f111 4 ��J14'�i. <br /> l <br /> kxaCASe'i .�'q. `h 1�1'' 'Ll �►RoY,t t. r wi{ ,,�. •=.,.�1.. .a :'. 4,Yi S �.... ,l i, ll..h�;,. g <br /> Mall or deliver original signed claim form to: Office of the City Clerk <br /> City of Everett <br /> Business Hours: 2930 Wetmore Ave.,Ste.x.-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 /> ca 14lit ell le-r6,11 <br /> Last name First Middle QDate of birth(mtn/dd/yyyy) <br /> 20 <br /> 2,Current residential address: 6'f 6 - V A ir-e. 2h�'-y a,-e 4 l) qR- I <br /> 3,Mailing address(if different): <br /> 4.Residential address at the time of the incident(If different from current address): <br /> 5.Claimant's telephone number: `e- 2s i ' 2 3) -`f Y `2 I9 <br /> • <br /> Home Cell Business <br /> 6.Claimant's e-mall,;address: );('t.1..uLtr.0..► .e,v u fviat I r Gcn,ii <br /> INCIDENT INFORMATION: <br /> 7.Date of incident: Si.)+ •Z. ' 13 Time: 0 a.m. ❑p.m. (check one). <br /> (mm/ddfyyyy) <br /> 8.If the incident occurred over a period of time,date of first and last occurrences: <br /> from: f-a Time: 0 am. 0 p.m.(check one) to 3 Time: Q a,m. 0 p.m,(check one) <br /> (mm/dd/yyyy) (mm/dd/ ) <br /> f, <br /> 9.Location of incident: W if� nrt.e t.2ciw►'IL P G to t4S �.¢, ire 404 <br /> - <br /> State anF1 county C/ly,If applicable Place where occurred <br /> 10,If the incident occurred on a street or highway: <br /> Name of street orhighway At�t}il a Intersection with or nearest <br /> Intersecttngstreet <br /> Rev.07/09' .[.` o •4 _4 _'rys 4 '! , -e 4 1 Vl.c(,tQc�v. , <br /> as AA- <br /> 1 <br />