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<br /> Erf. n- TORT CLAIM FORM
<br /> SEP 10 2013
<br /> Rev 07/09
<br /> Pursuant to Chapter 4.96 of the Revised Code of Washington(RCW), CITY OF El/BRETT
<br /> this form Is for filing a tort claim against the City of Everett, Some of
<br /> the Information requested on this form is required by RCW 4.96.020 ic.itl Cleric
<br /> and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim 0.
<br /> designated agent for the purpose of receiving claims. Claim forms 7tiq--1 -3
<br /> cannot be.submitted electrairlcally(via e-mail or fax).
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<br /> Mail or deliver original signed claim form to Office of the City Clerk
<br /> City of Everett
<br /> Business Hours: 2930 Wetmore Ave-,Ste.I-A
<br /> Mon.-Fri.,8 a,m.to 5 p.m.,Pacific Time Everett,WA 98201
<br /> Closed on city holidays
<br /> CLAIMANT INFORMAT/ON:
<br /> 1,Claimants name: Lberl t r)). (--, Acv-,Ailr‘olfii .,
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<br /> Last name First Middle Date of birth(mrh/dd)011
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<br /> 2.Current residential address: 1-1-(:)-5 \A)0.., f\-\Osre.--) ., --,0-Q-Are.-)-11 , 01-1 1
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<br /> 3.Mailing address(if different):
<br /> 4.Residential address at the time of the Incident(if different from current address):
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<br /> :::1 a rys,IL>
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<br /> 5, Claimants telephone number:(I 5/ q 3 3 CLir ai A I
<br /> ,Home . . .
<br /> 6.Claimant's e-mall address: lA-:-Q.4 k.s, Cell
<br /> A0)-1-,,......S?<11,1.ark e..) j'-'-i--(4.,---)wilsinA\s's ,. (_,e) IAA
<br /> INCIDENT INFORMATION:
<br /> 7.Date of incident: $3 I.19 a()I--,-) Time: '..--' , — Dam. )06&p.m. (check one)
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<br /> B.If the incident ccurr over a period of time,date of first and last o,cairences: a , ,,,,
<br /> from: C5)Act le"13 Time:(P,46) 0 a.m.)Q p.m,(check one) to qi Q013 Time:1, .3L---"pl<an. (check one)
<br /> 30.1-A17 (mmici/Wyy) . (mmidd/wyr)
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<br /> 9.Locatiori of incident: 6t L t VN ItikZ)Vt L eM-
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<br /> State and cos* City,If applicable Place where occuned
<br /> 10.If the incident occurred on a street or highway:
<br /> L-1-05 c4\A/ r-rt \ ....,-2F AQ Fu0A-vi:t-
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<br /> Name of street or highway _..) At Oh Intersection with.br nearest interseaag street
<br /> Rev.07704
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