6319 WETMORE AVE 2022-05-31 - Laserfiche WebLink

f City of Everett Use Only RECE IVED ,001/4 iii,.... 1 + erf TORT CLAIM FORM Rev.Q7/OS OCT 02 2013 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 t the information requested on this form is required by RCW 4.96.020 City Clerk 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). 6CW la 00 g55d4 PLEASE TYPE OR PRINT CLEARLY-IN INK Mall 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.Claim nt's name: , $ Last name Fir Middle Date of birth( m/dd/ ) 2.Current residential address: 4. ?/9 &I ?/a A lam 3.Mailing address(if different): ; ;qr)-f 4.Residential address at the time of the incident(if different from current address): I ` 5.Claimant's telephone number: i� 3y7-7?/7. ', 75 -4/ ,r Home Cell Business 6.Claimant's e-mail address: �� ,' l'r, t'- d..f�-7'` IiJE INCIDENT INFORMATION:7.Date of incident: ON ,479. NC3'3 Time: 6 30 ❑a.m. lel p.m. (check one) (mm/dd/yyyy) 8.If the incident occurred over a period of time,date of first and last occurrences: A, from: Time: ❑a.m. 0 p.m.(check one) to Tim ❑a.m. 0 p.m.(check one) (mre/dd/yyyy) (mm dd/yyyy) 9.Location ion of incident: /4/ ,— /,4/e)/iv� y i i. it State and county City,if app//cable Place where occurred 10.If the incident occurred on a street or highway: b/e-rr�i'P > t/ — ° -.1\&4 ' -> &- R--& in "2 to / co%) Name ofstreet or highway At the irate section With or nearest interkecting street