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v v <br /> i <br /> "Ak. <br /> Rf EDerm <br /> „. <br /> TORT <br /> CLAIM FORM SEP a 3 2013 <br /> Rev,07/09 CITY OF EVE TT <br /> • <br /> Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), City Clerk <br /> this form is for filing a tort claim against the City of Everett. Some of �j <br /> the information requested on this form is required by RCW 4.96.020 OEM .- 3 <br /> and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No. <br /> designated agent for the purpose of receiving claims. Claim forms ( `►O/._ 13 <br /> cannot be submitted electronically(via e-mail or fax). <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. 1-A <br /> Mon.—Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 <br /> Closed on city holidays <br /> CLAIMANT INFORMATION: <br /> 1. Claimant's name: <br /> LasAJ/FLe5/11 <br /> e First Middle Da e of bilM(inm/dd/yyyy) <br /> residential address: 1' . f 1LU• "/ �/ - 06 14' <br /> 9` Q <br /> 2.Currento� �? <br /> 3. Mailing address(if different): -6a In <br /> 4. Residential address at the time of the incident(if different from current address): <br /> 5. Claimant's telephone number: a5--- .5`. —c94`// <br /> Home • Cell Business <br /> 6.Claimant's e-mail address: <br /> INCIDENT INFORMATION: <br /> 7. Date of incident: r � c7` Time : d- (2O ❑a.m. Non. (check one) <br /> (mm/ddtyyyy) <br /> 8.If the incident occurred over a period of time,date of first and last occurrences: <br /> from: Time: ❑a.m. 0 p.m.(check one) to Time: 0 a.m. ❑p.m.(check one) <br /> (mm/ddlyyyy) (mm/ddlyyyy) <br /> 9. Location of incident: ___ i! »f?" _______ i �______—_ /0", ht' <br /> State and county City,"applicable Place where occurred <br /> 10. If the incident occurred on a street or highway: <br /> Name of street or highway Attie intersection with or nearest intersecting street <br /> Rev.07/09 zz <br /> (///d <br /> { <br />