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r � REcEi :„e TORT CLAIM FORM OCT 21 2013 Rev.07/09 CITY OF EVER ETT Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), Clerk this form is for filing a tort claim against the City of Everett: Some of 1 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 t5(1 .- cannot be submitted electronically(via e-mail or fax). tad Q4eAr 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: 3roa&133a CC-C. LO.n�{ ' n.11 S;�v , e-a ci ( ru& b�eb w - COMA) Last name J First Middle Date of birth(mm/dd/yyyy 2.Current PereWaddress: 0102 roa. .t3oa.t 6.Je.J V A9$aoi 3.Mailing address(If different): J 4. Residential address at the time of the incident(If different from current address): 5.Claimant's telephone number: aOb-$51-- g7y qPS D.c2.-1244 Home Cell Business 6.Claimant's e-mail address: INCIDENT INFORMATION: 7. Date of incident: O' /9-91 O 13 Time: 5.'3() ❑ a.m. lXp.m. (check one) m m/dd/yyyy) 8.If the Incident occurred over a period of time,date of first and last occurrences: from: Time: ❑a.m. ❑p.m.(check one) to Time: ❑a.m. ❑p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: \iill- 5-nokormt Eilere l coct& , q Icre11.7 State and county City,If applicable Place where&dcurred 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 / 1