Laserfiche WebLink
A�1��.1.���� <br /> E TORT CLAIM FORM SEP 17 2U13 <br /> °<�.�"", �Ii7'X pP EV�RETT <br /> Pursuan[to Chapter 4,96 of thc Revlsed CoAe of Washing[on (HCW), �j� C,��'I <br /> lhls form Is for flling a tort dalm ogainst the Qry of Ev�rett� Some of A x <br /> the InformaUon requesteA on thls form Is requlred by RWJ 4.9G.020 �iiy cic�ciaun o <br /> and may be sWJect ro pu611c dlsclosure. Tho CJry qerk Is tho pty's I^ �- _ I`� <br /> designa«d �9ent tor the putpose of receivtug dalms. Clalm forms / � <br /> cannotbasuGmlltsde:fnctronicalfy(vlae-mnilorlaxJ, ����30Da�f� <br /> [�.--u�'s�.�TP73��'i��'"'�9�s"iaY'�..�'r�[�i�'��;�'b'�T�''.����i�s.�i�.`;!�'�,`�i�✓�a1��'t�,.�'9i:.�"i�".¢"',�! s�f?�.' <br /> Mall or deflver otlglnal sl�netl claim form to: Clty of Everattity Clerk <br /> Ousiness Nours: 293a Wetmoro Ave.,Sto. 1-A <br /> Mon.—Frl.,8 a.m,tn 5 p.m.,Padfic 7ime Everett,Y�A 98201 <br /> Closed on clty holideys <br /> CLAIMANTINFORMATION: <br /> 1.Clalmant's name: /]�� � <br /> �ellc-� �I�a�l /�/� a—�—s�- <br /> —� F��� M/ddfc Ualeofblrtl�(min/di/YiyY) <br /> [ast name <br /> 2,Currentresldentlaladtlress: �DDOZ Grancl__ L✓e�¢� �1�dol - <br /> 3.Matling address(If dlfferent): SaF'}�.� <br /> A.Resldentlal address at��tlme of thc Inddenl p(diRcrent fmm curtent address): <br /> SCi m e_ <br /> 5.Ualmant's lelepliono numbcr: �� a�D�7aO� <br /> crn a�:N�� <br /> G.Clalrnanik c•mall address: _b' �P H 1��—G 1'0 7 � C p IYl .-- � <br /> IN .I�INFORMATION: ��J <br /> w <br /> �02� o��/3 �lme: = t U a.m.�,m. (check one) <br /> 7,Oatc of Incident: _ - <br /> (miN dIVNY) <br /> e.If U�e incident ouurred over a perbd of Ilme,date of Ilrst and last ocarrences: I <br /> (�n', 71me:_.- ❑a.m. Cl p.m.(chcck onc) <br /> Tlmc: �am. 0 p.m.(chr.dc ooc) �° �mm/Od/YWY1 -- / <br /> (mm�delvVrv) P_ .��� ��/1�( <br /> Wl �S/lo�lo/�t%5�1 FVer'p�'C=-- � i <br /> 9,I.p�aUun of Incident: --�� i ph,��Aop//�ble Place Nhr!e omurzd �j , ' <br /> STafc enArounty �VQ/ <br /> 10.If Ihe Incldent occuRed n a slreet or ldgM1way: <br /> Namraffieetcr �9AK�Y AtMelnhrSeeNonwlMaliaamsiln(Cistt7uu�aGcef <br /> qov.07709 <br /> 1 `'� <br /> �. -1� `� � <br />