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. ty t. IA ir_ .___ _ <br /> i#4411 <br /> vitg, TORT CLAIM FORM NOV 2 0 1013 <br /> Rev.07/09 <br /> Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), . <br /> this form is for filing a tort claim against the City of Everett. Some of City Clergy <br /> the information requested on this form is required by RCW 4.96.020 <br /> and may 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 D QV-) — R <br /> cannot be submitted electronically(via e-mail or fax), I <br /> t 3o0A-{btib <br /> PLEASE pt R,I h?tN'i CLEARI�i_IN'IN - <br /> . _ � � .: :�... r �. - - ._, r, .oz.- ,.....,4.v;-•r��.'.r."8.�4 c,..�.�r t C ..:..3:- },-.�.t... y i '.. 3 f.:- h �.. <br /> Mail 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:c,reni11, ,. give_!.; A <br /> gill a.A,,,-ehill <br /> S <br /> Last name First Middle Date ofbirfhi(mm/dd/yyyy) <br /> 2.Current residential address: rt ITI mn S f <br /> i <br /> 3.Mailing address(if different): 4,1 r,Lr:� <br /> 4.Residential address at the time of the incident(If different from current address): <br /> Q <br /> 5.Claimant's telephone number: g -,: - .33a-7/ . <br /> Home Cell Business <br /> 6.Claimant's e-mail address: . <br /> INCIDENT INFORMATION: <br /> 7. Date of incident: 2/,.rr :7 0/ ? Time: ❑a.m. ❑p.m. (check one). <br /> (ff idd/my) <br /> • <br /> 8. If the incident occurred over a period of time,date of first and last occurrences: <br /> from: /Y�.% Time:' Li a.m. ❑p.m.(check one) to Time: D a.m. D p.m.(check one) <br /> (re /dd/yyyy) (mm/ddlyyyy) <br /> 9. Location of incident: ,i /- <br /> State and county City,If applicable Place where occurred <br /> 10.If the incident occurred on a street or highway: <br /> Name of street or highway ��,y At the intersection with or nearest intersecting street <br /> Rev.07/09 <br /> //3 , <br />