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I to City of Everett Use Only0#111/P , ' CEIVED 4040/...„ viiii;"1 TOR CLAIM FORM Rev.07J09 NOV 20 2013 .. Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETT 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 4.96.020Clerk 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 41C 13 cannot be submitted electronically(via e-mail or fax). i 300 , 46 PLEASE PE RMTA11 GL ,t�RLY ,IN'1NK i r I.. iii y` . a. `t ._ 1 . . ,f 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:.' PIVia) lit)) cL- b -iom— Last name , - First j Middle Date of birth(mm/dd/yyyy) Z. Current residential. address:: 011+1 � 6 c.E' Vie- --(. - Rik- cg-� . " t1 [ 3. Mailing address. (if different): 5�� - 4. Residential address at the time of the Incident (if different from current address): DV 5. Claimant'si' `r 6-0 9 S!/ 11 .1 A-7D e telephone number: - euine6. Claimants a-mail address: If31l4d'iV14+1'I'k.�flJJi C .. 4A4/rr� • 6 INCIDENT INFORMATION: 7. Date of incident: Time: 0 a.m.. El p.m. (check one) (mm/dd/yyyy) 8. If the incid nt occurred over a period of time,date of first and last curr nces: ' from: Time: ❑a.m. ❑p.m. (check one) to I t 0 ii3Time: ❑a.m. ❑p.m.(check one) m/d yy y}_ ( m/dd ) CJ „ 9. Location ((�� r3 C h,,, , 'n of inciden 5c. d State and county. City, If applicable Place 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' /14°