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f .' City of Everett Use Only /114"14mi amP RECEIVED 'AIG; TORT CLAIM FORM /� Rev.07/o9 OCT 0 8 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY � � this form is for filing a tort claim against the City of Everett. Some of ERETT the information requested on this form is required by RCW 4.96.020 Cifr Cl¢r. and may be subject to public disclosure. The City Clerk is the City's City Clerk C(I m o. designated agent for the purpose of receiving claims. Claim forms /)r` ?\S ' C')-J cannot be submitted electronically(via e-mail or fax). 6-C22,013004ses- 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 name: Last name First Middle Date of birth(mm/dd/yyyy) 2 rli sidential address: Z l('. Z roaciu Xj givrog-� NA. 1 3. Mailing address(if different): 4. ut• address at the time of the incident(if different from current address): ci 13s ti t.1, 6 2 t1 1,dloi 1�`Z4 5.Claimant's telephone number: ?"�-.1J'17 ,�/prn � Cell Business 6.Claimant's e-mail address: q t�1't(�1�lyP v V Co/ INCIDENT INFORMATION: 7. Date of incident: efrcklI3 Q A QI5/r3 Time : \IQ0110(2S ❑ a.m. V p.m. (check one) (mm/dd/yyyy) 8. If the in idea occurred over a period of time, date of first and last o cur ences: from: VP--1j3 Time: CIa.m.„Rpm (check one) to 1 .. /3 Time: ❑a.m. A.m. (check one) (mm/d IYYYY) (m /d / ) W0,5 1 it: �ii s /4,61, r o2(Q5 &&^cx,AWa\i 9. Location of incident: ��(- State and cobdnty 3 City,if applicable P/ace where occurfed 10. If the incident occurred on a street or highway: Name of street orhiyhway At the intersection with or nearest Intersecting street Rev.07/09 //.4(°-