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<br /> • racy OT Everett•use onry
<br /> ierit-0. RECEIVED
<br /> 4167--iti
<br /> Ev.2 TT TORT CLAIM FORM
<br /> SEP 1.3 2013
<br /> Hev.07/09
<br /> Pursuant to Chapter 4.96 of the Revised Code of Washington (ROW), CITY OF EVERETT
<br /> this form is for filing a tort claim against the City of Everett. Some of
<br /> the information requested on this form is required by RCW 4.96.020 City Clerk
<br /> and may be subject to public disclosure, The City Clerk is the aty's City Clerk Claim No.
<br /> -.-) - --
<br /> designated agent for the purpose of receiving claims. Claim forms -3 13
<br /> cannot be submitted electronically(via e-mail or fax).
<br /> 6-CVC))30 0 41
<br /> WCE:iigkt*--#Etik:iiiRliilf-Ci:t441y4147011k:1," ''''i:"'1!'72. -:- ,i:472,;:J. 4.1;---7;'-''''''a-';:::',71-:.---- :):::-,--- -"',-• y's.,.,.....'-::".i-4.,'::-..,:'
<br /> Mail or deliver original signed claim form to: Office of the City Clerk
<br /> City of Everett
<br /> Business Hours: 2930 Wetmore Ave.,Ste.1-A
<br /> Mon.-Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201
<br /> Closed on dty holidays
<br /> CLAIMANT INFORMATION:
<br /> 1, Claimant's name:fin))u Pdie‘\icI 4 EL
<br /> C (
<br /> - ')(1 11 /7 4(1 1 . I i
<br /> 40 19 ell
<br /> Last name I first Middle Date of birth finitn/d/yyyy)
<br /> . , .1 1 isf,/,
<br /> 2.Current residential address: IT L6e, 6ipe. Al.,Y__ 5 WA-i 7 ti, 2‘)/
<br /> 9- -hrt ' aeifel--
<br /> i
<br /> 3. Mailing address(if different):
<br /> 4. Residential address at the time of the incident(if different from current address):
<br /> 0-1/4-e S ailoolik—
<br /> i - ....... ..... ' k
<br /> '7 )-, )126 2c9 /4(26 5. Claimant's telephone ntirnber (2_5 7 ,..- -,.- , -(._ ,
<br /> Home
<br /> 6. Claimant's e-inail address: ‘ "OA fs-rtte.-41
<br /> INCIDENT INFORMATION: . S-Ce-Oil-4 eitate, 11,9‘ e/in-e-$04-'
<br /> 7. Date of incident: 00 ..../-7 At),/3
<br /> imiddh —2.-..../. ...iTi/me L A i"-it/Ce/6/ '+ 4urlia'inlif.-171/117.111*86u i(checket-nel di one)g)
<br /> ,..L. e. ear,e-t ,ua sx trivAvr ekt og,f r
<br /> 8.If the incident occurred over a period of time,date of first and last occurrences:
<br /> from; Time: El a.m. D p.m.(check one) to Time; 6 a.m. 0 p.m. (check one)
<br /> (MilVdd/YYM (mmidd/ywy)
<br /> , , 4_ , ,,i i
<br /> 9. Location of incident: 1A-J.17-511,07V6- i 0./t/ ,5Ailo# ek-reeyi pe.61 /onctz...)
<br /> 1 . \'- -
<br /> State and county City,',applicable Place where occurred
<br /> 10.If the incident occurred on a street or ighway:
<br /> a)
<br /> ri 1 thil.Orr-,
<br /> 7
<br /> ame of street or hway A / 0 1 A. i At the intersect/on with or nearest Intersecting street
<br /> it' 4ikt,IU i
<br /> Rev.07/09 ,iL...-
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<br /> pirne,E SEE 47_,T46?voles73 /- '7 F
<br /> 3 9-- -
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