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City of Everett Use Only <br /> "v-7 - . • <br /> , ,EY ToRr CLAIM FORM <br /> Rev.07109 <br /> SEP 19 2013 <br /> Pursuant to Chapter 4,96 of the Revised Code of Washington (RCW), <br /> this form is for filing a tort claim against the City of Everett, Some of ary OF EVERETT <br /> • the information requested on this form Is required by RCW 4.96.020 'i°i Cleft <br /> City Clerk G'Fet i <br /> and may be subject to public disclosure. 7'he Clty C{erl<is the City s 7 }} <br /> designated agent for the purpose of receiving claims, Claim forms 17t 0 " t3 <br /> cannot be submitted electronically(via e-mail or fax), <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 /> Mort.•-.Fri.,8 a.tn.to 5 p.m.,Pacific Time Everett,WA 98201 <br /> Closed on city holidays' <br /> CLAIMANT INFORMATION <br /> 1.Claimant's name: <br /> A -- �. � <br /> Last name first Middle Date of birth(arm/dd/yyyy) rtv <br /> 2.Current residential address: \\,11 Z� S to . <br /> 3.Mailing address(if different): ` t'Z (AS `St " <br /> 4.Residential address at the time of the incident(If different from current address): <br /> _ <br /> 5.Claimant's telephone numbert053 —/` LA y, I <br /> nn ,e .-�l(oin Cell Business <br /> 6. Claimant's e-mail address: ;t ttt <br /> INCIDENT INFORMATIQN: <br /> 7, Date of incident: (Yb I acl: \ Time: `I"S' vY ❑a.m. %, p.m, (check,one) <br /> (nuo/dd/yyyy) <br /> 8, if the incident occurred over a period of time,date of first and last occurrences: <br /> from: Time:_ 0 a.m, El p.m.(check.one) to Time: 0 a.m. El p.m.� (check one) <br /> (mmydd/YYYy) (mm/dd/yyyy) <br /> tr- C ^c-Csl <br /> 9. Location of incident: ��1I� + 51 t�l Cs `s� . . � Q ' t "i--4r <br /> State and county City,if applicable Place where occurred <br /> 10.if the incident occurred on a street or highway: <br /> /QOine of street orhighway At the intersection with or nearest Intersectriu sheet <br /> Rev,07109 <br /> ./P <br />