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11 <br /> City of Everett Use Only <br /> 77 roRr CLAIM FORM <br /> S , <br /> REcII -TE i\ . i <br /> DEC 6 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 RCVV 4.96.020 <br /> and may be subject to public disclosure. The City Clerk is the aws City Clerk Claim No. <br /> designated agent for the purpose of receiving claims. Claim forms D';'x)t-I - 13 <br /> cannot be submitted electronically(via e-mail or fax). <br /> G.C2015 0044011 <br /> **ASE11. 1.0,4;00;10.00-'CLEARLY :$N INK <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. I-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: . , it n 't‘ <br /> A.--6/6w3 J-1-?s50(it Av41 -1,1-ale-her <br /> 1 <br /> Last name i First Middle Date of birth(mm/dd/yyyy) <br /> , <br /> 2.Current residential address: ("II/ 7 6ver-gr-ee/7 1 eft-- <br /> a95 e4e -e›11-- <br /> 3. Mailing address(if different): g/All <br /> 4.Residential address at the time of the incident(if different from current address): <br /> 5. Claimant's telephone number: .70&6/7e)-672c-- --- <br /> _i, _1 Noe . .., .. ...cell Business <br /> 6. Claimant's e-mail address: ( ii..c i 7 jai , ..,-„, (-2.5... ,1-9 _c..4--.4., G Ly ,iia) ,(7c <br /> INCIDENT INFORMATION: <br /> v i,,,, ...._,) <br /> 7. Date of incident: ?) --D-61 **-'LIU t..,.. Time: EI a.m. 0 p.m. (check one) <br /> (tnrn/c1d/yyyy) <br /> 8.If the Incident occurred over a period of time, date of first and last occurrences: <br /> from: Time: 0 a.rn. 0 p.m.(check one) to Time: D a.m. 0 p.m.(check one) <br /> (rnmiddiyyvy) (mmickvyym <br /> 9. Location of incident: WA' j 5170//00/i3k7 4-- ( 674 1,7€,) <br /> State and colmfr City,If app'&able Place where occurred <br /> 10.If the incident occurred on a street or highway: <br /> 'tirpe.,K: ee I r, ± tx-_,4 / <br /> ci.„27 <br /> Name of5r orhighTy 3t the intersect/on with or nearest Intersecting street <br /> , , <br /> Rev.07/09 i2- /n i eifiz' °I71 i'r -; <br /> 03 : <br /> = <br />