625 WETMORE AVE 2022-05-31 - Laserfiche WebLink

01P:j REtE1VD TORT CLAIM FORM SEP 0 3 2013 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 City's City Clerk Claim No. • designated agent for the purpose of receiving claims. Claim forms cannot be submitted electronically(via e-mail or fax). 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. Claimant's name: Gordon, Sharon Lee 03103/1959 Last name First Middle Date of birth(mm/dd/yyyy) 2. Current residential address: 625 Wetmore Avenue 3. Mailing address(if different): 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: 425-252-9161 425-512-7356 6. Claimant's e-mail address: shar�°�'i..Egordon@boeing.com Cell • Business INCIDENT INFORMATION: /' G 7. Date of incident: O8/29/13 Time : 7%" [ ❑a.m. 121 p.m. (check one) (mm/dd/yyyy) 8. If the incident occurred over a period of time,date of first and las grgsc��,rie ces: 900 from: 8/2 9/13 Time: 7 0 0 III a.m. p.m.(check one) to // . Time: ❑a.m. (3(p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: Washington Snohomish Everett State and county City,if applicable Place where occurred 10. If the incident occurred on a street or highway: Wetmore Avenue 6th Avenue Name of street or highway At the Intersection with or nearest Intersecting street Rev.07109