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TORT CLAIM FORM Rev.07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), 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. designated agent for the purpose of receiving claims. Claim forms cannot be submitted electronically (via email or fax). OCT 0 8 2013 CITY OF EVERET ' . City Clerk City Clerk Claim No. 12�0- • t92 �QDt vrr,HSFs? _ - - - PLEAS�'�YP� Mail or deliver original signed claim form to: Business Hours: Mon. - Fri., 8 a.m. to 5 p.m., Pacific Time Closed on city holidays CLAIMANT INFORMATION: 1. Claimant's name: Office of the City Clerk Clty of Everett 2930 Wetmore Ave., Ste. 1-A Everett, WA 98201 A� A p% '� bu " is - t 1 _I Last name. First Middle Date ofbirth (mm/dd/yyyy) 2. Current residential address: 3Crr a1 l Ili 1 A NT aK% t2 F--- JAS Nf=- A s N"4 . S i 3. Mailing address (if different): 4. Residential address at the time of the incident (if different from current address): 5. Claimant's telephone number: 10 72-2- -2LA-2- 3 (> -42-T 573Db Home cell Business 6. Claimant's e-mail address: ArQ,9 t"' N Tr--P.PFSl S I14CIDENT INFORMATICON: 7. Date of Incident: P 51 -2 mm/dd/yyyy) -rime: Ml00 a.m.Xp.m. (check one)" 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: 22T I a 13i,,"O/ VVA`i V2:\I 5IN o V+0 State and county city, Ifapplicable Place where occurred 10. If the incident occurred on a street or highway: t t tzC; A DV_J PC't N AM IAT ?_S E -X i ON 1l 9EC A-V Name ofstteet or highw y At the intersed#lon with or nearestintersecft street Rev. 07/09 f .---