711 WETMORE AVE 2022-05-31 - Laserfiche WebLink

Cl of Everett Use'Onl cEi . . , .... T .. . . ......... ORr cLA.r . OCT„iiiii;e 07 2013 Rev.07/09 nr Pursuant to Chapter 4,96 of the Revised Code of Washington (RCW)r ' �/x OF �T aET'1�' this form Is for filing a tort claim against the City of Everett Some of - Ci , • the Information requested on this form is required by RON 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 12< `o -. t cannot be submitted electronically(via a-mall or fax). [.. oLQ 13vo 41577 ry �.+ .� ,y fig .�' cr ,P' �j - . . a 'fir ``w r�i LS-E Ln rainnFs �P.._ HISS� � il [ dEG�t .; f�. ��." o..rc ,. n -+�.45' 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: ,(. Last name Ma deB L� Middle Date of birth(mni dd/my) • 'ram 2,Current residential address: 71( 4C7►Yr%t)(€, 91 WA 49201 3.Mailing address(If different): .. _ 4 Residential address at the time of the incident(If different from current address); d7 5 42.0 1923, 47 .2/7 5.Claimant's telephone number; 2 ' +r �// 13olnew 51) 6.Claimant's a-mall address; OW WRAneblcJ4?3 (h()+1014, com INCIDENT INFORMATION: l vr ( Time; 0 a,m, El p.m, (check one) • 7.Date of incident: �� ii t��j (mm/dd/yyyy) 8,If the incident occurred over a period of time,date of first and last occurrences: from: Time:,.. 13 a.m. 0 p.m,(check one) to Time: 0 a.m. R p.m.(check one) (mm/ddlyyyy) (rnm/dd/yyyy) 1(1 *brow, At C, gg2o I 9.Location of incident: i co ( �` /61(e 1' Place where acru state d unty tY.If applicable 10.If the Incident occurred on a street or highway; Name ofstreetorhighway At the intersection with or nearest Intersecting street Rev.07109 1