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REry�E���UV���� <br /> � TORT CLAIM FORM SEP 16 2U13 <br /> Ncv.07/W �+i� L� E� <br /> Pursuant lo Chapter 4.96 0( the Revised Code of Washinglon (RCIN), CI l 1 Or� � Y �`Z' ' �. <br /> thls form Is for filing a �ort daim against the City of Everelt Somc of CJt�/ ���ic '� <br /> lhe information rcquested on thls form Is required by RCW 4.96.f170 <br /> and may l�e subjed to pu6lic disdasure. The Ciry Clerk is the City's c�ry cie Clalm No. <br /> designalcd agcnt (or the purpose of remiving daims. Claim famrs ,�ji�-3-13 <br /> c:rnnotbesubmiKeddectronicalry(viae-mal/orfarJ. ���300�505 <br /> PL'EASE TYPE OR��FRINT•CLEARLY� IN TNK � . � � . � <br /> Mail or deliver original signed daim form to: Office of the City Clerl� <br /> City of Everett <br /> Business Hours: 2930 We[more 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 /> LLAIMANT INFORMATION: <br /> 1. Galmant's name: <br /> _1.7_u.��✓ �S�rm m ��_- J7/tv�� � 3� /-S5 � <br /> Lasf nam: —� � firsl AJIdAJc Dafe ol b°lMh(mm dA/yyy/J <br /> 2. Current reslclential address: _ o15oZS d��i/1Y��_ ..�'7vi-���-Z��� w�9 • 9��Zx7� <br /> 3. P1ailing address(i(difierenl): _ —_— <br /> 4. ResiAential address at the time of the Inciden[(if diFterent from current address): <br /> 5. dalmant's telephonc nwnber. _ __ �/c1S �'y7/� ZGZZJ <br /> Honrc Cdl lluslness <br /> 6. d:drnaid',e-mai�add�css: _ /f�i�y• �UNnI(� yA-fh'O.['.4 — <br /> INCIDENTINFORMATION: � <br /> 7. Dale of inciden[: 8 Z 9 Zo/ _ Time : � ��a.ai. L'f p.m. (check one) <br /> , mmlddlnw) - — <br /> 8. If lhe In�ident o[currcd ovcr a perlod nf timc,datc of firsl and last o�c,a/m�e[[[n[es: <br /> fiom:��7-�f/�71mc:___L ❑a.m. [Tffr.m.(chcdc onej lo�/�•'13flmc:_��U C�a m. CI p.m.(dittk onc) <br /> (mm/dc�yyyy) (mifi/d �YYVY) <br /> 9. LocationoffncidenL• W• �--ESNC�LfylYlisN��_�..-�^�-�5�-lYI�T <br /> Sfr:candmunly �City,ilapplicaL/c Plam ivhem oaurm� <br /> 10. If Ihe 0uident occurred on a slreet or highway: . <br /> Ramc of stmcl or/r.g/nvay Af Brc inh�rsert/an w/Ui<r ncaresf l,akrsecirng 5,7tr! <br /> Rev,07109 �\ <br /> l I <br /> /�. <br />