Chapter 2.35
TORT CLAIMS
Sections:
2.35.010 Instructions and form adopted.
2.35.020 Instructions for completion and presentation of tort claim (Chapter 4.96 RCW).
2.35.010 Instructions and form adopted.
The board of commissioners of Cross Valley Water District of Snohomish County, Washington, hereby adopts instructions and a form for presentation of tort claims pursuant to Chapter 4.96 RCW in the form set out in Appendix A of this chapter. [Res. 2014-6-6.]
2.35.020 Instructions for completion and presentation of tort claim (Chapter 4.96 RCW).
(1) Complete the tort claim form maintained at office of registered agent as recorded at the office of the Snohomish County auditor.
(a) Registered agent: general manager.
(b) Office location: 8802 180th Street SE, Snohomish WA 98296.
(c) Business hours: 8:30 a.m. to 5:00 p.m. Monday through Friday, except holidays.
(2) Tort claim form must be typed or printed clearly in ink.
(3) Provide all requested information and any available documents supporting your claim.
(4) If the requested information cannot be supplied in the space provided, please use additional blank sheets so your claim can be easily read and understood.
(5) Sign by authorized party and have notarized.
(6) Present properly completed and signed tort claim form in one of the following manners:
(a) Personal delivery to registered agent or authorized person in office of the registered agent during above business hours.
(b) Deliver by registered mail to registered agent.
(c) Deliver by certified mail (with return receipt) to registered agent. [Amended during 2015 codification; Res. 2014-6-6 (Att.).]
Appendix A Claim for damages.
CROSS VALLEY WATER DISTRICT
Claim for Damages
Chapter 4.96 RCW
To the registered agent of Cross Valley Water District
Please take notice that (full name) ____________________________________________________
(Date of Birth / / / )
Who now resides at ________________________________________________________________
Daytime phone # ________________
Who resided at ____________________________________________ at the time of injury/damage?
Claim damages from Cross Valley Water District (in the amount of) $ _________________________ arising out of the following circumstances: (Please answer the questions below)
What happened? _________________________________________________________________
_______________________________________________________________________________
Where? (Provide as much detail as possible including street address.) _______________________
_______________________________________________________________________________
When? (date and time) ____________________________________________________________
Persons involved/witnesses. (Include name & address.) __________________________________
_______________________________________________________________________________
Accurately describe injury sustained or items of damage claimed. Itemize all expenses and losses. (Attach extra page if necessary) _______________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Why is Cross Valley Water District responsible for this injury or damage?
_______________________________________________________________________________
_______________________________________________________________________________
Signed:
_________________________________________________________ (Claimant or representative authorized by RCW 4.967.020
Being first duly sworn on oath, deposes and says that __he is the above named claimant; that __he has read the foregoing Claim for Damages, knows the contents thereof and believes the same to be true.
Subscribed and sworn to before me this ___ day _____________________________, 20________.
Signature _______________________________
Printed _________________________________
Notary Public in and for the State of Washington
Residing at ______________________________
My commission expires ____________________
[Res. 2014-6-6 (Att.).]