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e i _ City of Everett Use Only • RECEIVED 44110,--A1 .411;Pf rr TORT CLAIM FORM Rev.Woe OCT O 1. 20 13 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETI' this form is for filing a tort claim against the City of Everett. Some of 4 the information requested on this form is required by RCW 4.96.020 City Clerk 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 j e 4— ,1 cannot be submitted electronically(via e-mail or fax). 5 6 ir P0ASE_C1(1?t.ORPRiNT'CL ARI.Y IN INK '' ,' ,: ' Mail or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste.I-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 Da a ofbl?t (mm/dd/,tyyy) 2. Current residential address: // 2,5" id e a) /11 f'rf /ii A/90a.J 3.Mailing address(If different); 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: ‘0-L2 yid' fr .7.)s---'70"S030 Nome Cel , Business 6,Claimant's e-mail address: ,5`L{S1//i/c ) .. i'vr-GUN:tr i ' POc ?�. PE.. C Civ' INCIDENT INFORMATION: 7. Date of incident: . Time El a.m. ❑p.m. (check one) . (mm/dd/yyyy) 8.If the incident occurred over a period of time,date of first and last occurrences: from: 8 Time: ,ka.m. ❑p.m,(check one) to D Time: ❑a.m. ,l p.m.(check one) 9 (mm/'/d, (mm/d NYYY) [ 9, Location of incident: 1414 Sl7 U 4 o tyl/6A C�'t�el ell .Jd/y zfraia eitt/eLy /i'e_, State and coun0/ Cily,If applicable Place where occurred opPe' 10.If the incident occurred on a street or highway: _ roce.duWci-i _mil/Y eke % A)1/ twat ,17 s Name of street or ighway At the Intersection with or nearest Intersecting street Rev,07109 0