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4 t <br /> City of Everett Use Only <br /> A141 • <br /> RECEIVED <br /> Tr TORT CLAIM FORM <br /> *ail <br /> Rev.07/09 OCT 08 2013 <br /> Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), 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 City's City Clerk Clai No. <br /> designated agent for the purpose of receiving claims. Claim forms [7(7 --' 1: <br /> cannot be submitted electronically(via e-mail or fax). . 'I <br /> 6-eaot Ast90g5 8if <br /> PLEASE TYPE OR PRINT CLEARLY IN INK <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 city holidays . <br /> CLAIMANT INFORMATION: <br /> 1. Claimant's name: <br /> Sand - 1Vi)6 L 1 NN < )'7-.SO--I(7 5 <br /> Last name V First Middle Date of birth(mm/dd/yyyy) <br /> 2. Current residential address: `I't & " 'A-", SE-, Api- A-5/ nve lAJA-� clg9C93 <br /> 3. Mailing address(if different): c5a wn..e-- a-S (-49X. <br /> 4. Residential address at the time of the incident(if different from current address): <br /> cL5' 4,60 u . <br /> 5. Claimant's telephone number: 21a5",9-5q 56ac 405--q'y/"8 1Y9 xU--A---- <br /> Home Cell Business <br /> 6. Claimant's e-mail address: r 1— '�c0i'j- ht.r.-u e-- 0 . <br /> INCIDENT INFORMATION: <br /> 7. Date of incident: C1 ` aa1 3Time: e 7 p 8pil, ❑ a.m. -p.m. (check one) <br /> (rnm/dd/YYYy) <br /> 8. If the incident occurred over a period of time, date of first and last occurrences: <br /> from: Time: ❑a.m. 0 p.m. (check one) to Time: 0 a.m. 0 p.m.(check one) <br /> (mm/dd/yyyy) (mm/dd/yyyy) <br /> 9. Location of incident: Stru o tii Snowhoivt)S�i — eileA-4- - Ill/ r- ,-4. 5.& HoT+ im <br /> State an ountji City,if applicable Place where occurred Floo r <br /> 10. If the incident occurred on a street or highway: <br /> Name of street or highway At the intersection with or nearest intersecting street <br /> Rev.07/09 / ///� <br /> /A s <br />