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

• City of Everett Use Only RECEIVED moi;e rr TORT CLAIM FORM OCTev.07/09 OCT 08 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERET this form is for filing a tort claim against the City of Everett. Some of the information requested on this form is required by RCW 4.96.020 City C11fL and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim o. designated agent for the purpose of receiving claims. Claim forms 173 ' -- cannot be submitted electronically(via e-mail or fax). GCao i Soo Lis si PLEASE TYPE OR.PRINT CLEARLY IN INK; 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: Last name First [9dIe Date of birth"mmjdd/. i t 1st C n�y1 2. Current residential address: 11 ! `+ 7 i 1- SE I1 EereiC, L,1,�`7 9 • 3. Mailing address(if different): 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: k3 tl? 'lc . -'% ` 1 k9 Home Cell Business 6. Claimant's e-mail address: INCIDENT INFORMATION: �l 7. Date of incident: Ali 9 j Q) 3 Time : r 4%6- El a.m. one) rp.m. (check ( /dd/YYYY) 8. If the incident occurred over a period of time,date of first and last occurrences: from: Time: ❑a.m. ❑p.m: (check one) to Time: 0 a.m. 0 p.m.(check one) (mm/dd/yyyy) � Q �`" (mm/dd/yyyyy) (fit 9. Location of incident: 11'1 / 7 "'F ND-t !- t.- `�-' l� e r tt `7 3j L) 5&I1fl e/t State and county City, if applicable r P/ace where occurred 10. If the incident occurred on a street or highway: Name of street or highway At the intersection with or nearest intersecting street Rev.07/09