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f . t , ••• 14 0110:110101q) 1 L. Eypry- TORT CLAIM FORM EP .r.'. ) 21)13 Rev,07/09 CITY ( .. i\y/.1..J. 7: 11 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), City CL.,,y`,„ 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 4.96.020 and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No. designated agent for the purpose of receiving claims. Claim forms Di 68 - 13 cannot be submitted electronically(via e-mail or fax). Cre.aoacio 445 ?, PLEASE TYPE OR PRINT CLEARLY IN INK 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 ame: ii Dt el j rrn- lyto -ftt\en II y2 11 ' Last name First Middle Date ef birth(mm/d./YYW) I 2. Current residential address: \ — - \ ) ,, ' i . 3. Mailing address(if different): 4. Residential address at the time of the Incident(if different from current address): ... - ) 5. Claiman bt's telephone number: -Lom,„ cyi-12 10/5(„.e 1st Efinly)' V2,,: A 21 Q-itli 4 + -0 2? Li lb 1?)'. 21--L-' 6.Claimant's e-mail address; Ck Atq c)(.1 Cli Tr INCIDENT INFORMATION: 7. Date of incident: OBI 20\ DI 1 ) Time (wool (t t P: _ a.m. p.m. (check one) (mm/dd/yyyy) 8. If the incident occurred over a period of time,date of first and last occurrences: from; Time; 0 a.m. 0 p.m.(check one) to Time; 0 a,m. 0 p.m,(check one) (mm/dd/yyyy) (mm/dd/yyyy) \ 0 1 \ 9. Location of Incident: Mt1 ,.)IS 'Offekt, Vkaftetra..., State And county City,If applicable Place where occurred 10.If the Incident occurred on a street or highway; Nci:) .1? Dr 16 )ir ( e ,..., 0k( Ave Name ofstreet or highway At the Intersection With or nearest IntetsT`Ing street Rev,07108