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.1 7 TORT CLAIM FORM Rev.o7lo9 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 farms cannot be submitted electronically (via e-mail or fax). City of Everett Use Only RECEIVEI)"� EP 2 3 2013 CITY OF EVERETT city Cie City Clerk Claim Nu, GG�c�aa��s .i►LEA�E,�11'PE�ii. i?i�I(�� CLE.��f��N�K." -.�;K.-��-n�..$.� 5 ' � rvx «. _ � f _� � ? _ __ � F� 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 CLAXMANT INFORMATION., 1. Claimant's name: Lastnairle First M/ddle Date ofblr#i (mmJdd/yyyy) 2. Current residential address: a-1 S f-)P_.Q Ab\A3.Ay , FNI W 1 3. Mailing address (if different): a 0g9,9 61-n-4 w ASt:1. T6 4. Residential address at the time of the incident (if different from current address): S, Claimants telephone number: _3( - L42"S— oOl 1 9_2 S__i�_Iso _ 2Z32 __ �_125 -'� '-Z.Z 3 ` ' Home Cell Busness 6. Claimant's e-mail address (C;C-eS 1� CtS e VJ Q. i 1(� V10++MGti 1 C C3�M INCIDENT INFORMATION 7. pate.of incident: A 0 40ST �ATA r 2�0) 3 Time: ❑ a.m. 10 p.m. (check one) (nim/dd/yyW) 8. If the incident occurred over a period of time, date of first and last occurrences: from: Time:, b' a.m. O p.m. (check one) to Time: ❑ a.m. D"p.mi (check one) (mm%ddlyyyy) (mmjdd/yyyy) oz 1I g 9. Location of incident; L1) lrl. -c>"oi-\oynu4 ,\A .i E c 2,214 E V e—PuIT, State and county Clay, if app'lcable Place where occurred 10. If the incident occurred on a street or highway:. Name of street or hlomy Atthelntersedim Wfll ornearestIblersecft street Rev. 07109'