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2 C 1 a i <br /> -4LE V <br /> R <br /> , <br /> rr TORT CLAIM FORM SEP 24 2013 <br /> Rev.07,09 <br /> Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETT <br /> this form is for filing a tort claim against the City of Everett. Some of City Clerk <br /> the information requested on this form is required by RCW 4,96.020 <br /> o. <br /> and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No. <br /> designated agent for the purpose of receiving claims. Claim forms r71 i — t 3 <br /> cannot be submitted electronically(via e-mail or fax). . <br /> 6-CP-016 004.543 <br /> Mall or deliver original signed claim form to; Office of the City Clerk <br /> City of Everett <br /> Business Hours: 2930 Wetmore Ave.,Ste.1-A ] <br /> Mon.—Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 <br /> Closed on city holidays . <br /> CLAIMANT INFORMATION: <br /> 1. Claimant's name: <br /> 4/e .3- e i .rn /4/8/Z <br /> Last name - First Middle Date of birth(mm/dd/yyyy) <br /> ..-,, <br /> 2. Current residential address: '7 ii;,z, r? <br /> g L a .1 no ;47...ki, 1.22(2, C/? <br /> 3. Mailing address(if different): <br /> 4.Residential address at the time of the incident(if different from current address): <br /> 5, Claimant's telephone number: z/,:g 6--- 3 <br /> 3Home Cell Business <br /> 6,Claimant's e-mail address: , YY7 e, <br /> . <br /> INCIDENT INFORMATION: <br /> 7. Date of incident: '3 - ;,1 q , 7 3 Time: 2 p.m Dam. %mi. (check one) <br /> . (rnm/dd/yyyy) <br /> 8.If the incident occurred over a period of time,date of first and last occurrences: <br /> from: g ....2q Time:...4 _13 a.m. Xp.m.(check one) to ?. '7 Time: L"...)erfl a.m.M.m.(check one) <br /> (mmiddhyyy) (tran/cld/yyyy) <br /> . <br /> 4 it:;-.bir-, <br /> 9.Location of incident: aa S,ry pm e # <br /> /_.) ,.. , - 7.g.2 2... i--: e a . 1 i 1 e, <br /> State and county Chy,If applicable Place where occurred <br /> 10.If the Incident occurred on a street or highway: • <br /> 7-g A ,:g L.-;? az.4 .s. in 0 , p- /, <br /> Name of streetor highway Attila intersection with or nearest Intersecting street <br /> Rev.07/09 <br /> 0.-/ <br />