1111 47TH ST SE 2022-05-31 - Laserfiche WebLink

• • City of Everett Use Only 414/6"A ECi E VE L f EL TORT CLAIM FORM Rev.07/09 'DEC 9 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY T ni � VT -, this form is for filing a tort claim against the City of Everett.. Some of Al the information requested on this form is required by RCW 4.96,020 O Clerk arid may be subject to public disclosure. The City Clerk is the City's City Clerk Claim a. designated agent for the purpose of receiving claims. Claim forms T/''0 )3 cannot be submitted electronically(via e-mail or fax). & 13004'15 PXEA5E,T3�!'�OI�'�RINT C�EARI;'Y-Th["x�1iIC„_ ;,�• .�_.__`- ._-. � ._ _<__...-�" ..:r,. - 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: 1��Y1i .ci a kALLI kira vA 49. llitp( 1 t Last name First Middle Date of birth(mm/dd/y yyy) 2. Current residential address: //(/ ^LI 4^' . • .C . - 3. Mailing address(if different): l-(D I j o A/iir) 9►-1 faits nil- h2 - '/ 4. Residential address at the time of the incident(if different from current address): 5, Claimant's telephone number: Home Cell Business 6. Claimant's e-mail address: INCIDENT INFORMATION . 7. Date,of incident: A u f a9,0706 Time _4/. ❑a.m. -o m. (check one) (mm/dd/yyyy) 8.If the incident occurred over a period of time,date of first and last occurrences: from: Time: D a.m. 0 p.m.(check one) to Time: 0 a.m. 0 p.m.(check one) (mmldd/yyyy) (mm/ddlyyyy)' 9. Location of incident: LU."'. -SPY5>A0?'1'Lt 1 State and county City,If applicable - Place where occurred 10. If the incident occurred on a street or highway: Name ofstreet or highway At the intersection with or nearest intersecting street Rev.07/09