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city of EVerett Use Only RECEIVED TORTa.A.rm FORM SEP 0 3 2013 Rev.67/09. , Pursuant to Chapter 4.96-of the Revised Code of Washington (RCW)., CITY OF EVEkETt: 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 4.96i.020 • it7YC14ir' -; and may be subject to public discloSure.. The CityClerk.is the,City's Ct Clerk Claim No designated agent for the purpose of receiving claims Claim forms 1-.)0‘.16 IS • cannot-6o submitted oloctrohically(ida e-mail or fax), • " _ . •. • #1100*P..0,1011114#640011tatiaNitaif-::W: Mali or deliver original fornito: _ Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste. 1.-A tin.;:to 5p m,Pacific Time Everett-,WA 98201 CIOSed ori:dtt holidays CLAIMANT INFORMATION: 1.Claimant's name: _ gti _ L 01.1,023//17r Last pain& _ - • - Fir>t - b*cotbo 2.Current residential address:: 7g qirmi Vc_ b0.0 grio3 3.Mailing address(if different):- • • 4:Residential address at the time of the incident(if'different from current address): • • - . - • 5. CiairrianVst6pliton number; _ _ ,:405-7,2349:7762,03 , .. _ . drn cell j'asinegy 6.Claimanfs e-mall address: C.A1/6(-1.1rti(re...1(oz.30,pl.! INCIDENTINFORMATION: 7i Date ofincident: CR/SR& , time :7 CO.- .y 0 a.m. p.m. (check one) (rumiddl/YYYY) 8.If the incident Occurred over a,period of time,date of first and last occurrences: from.... .. - Time: a0 D p.m.(checknne). to. Time: D a.rn. 0 p.m.(check one) (iruniddhyyq Olin/ad/MY) / 9. Location of incident: VaStlitilA aktetitelt4 -.kkiiir•-•*; • •tH/"..7 (7)ertea A &ate and unty ' Ory;itappi ble p/ where-Murree 10.If the.incident occurred on a street or highway: freet • • orhighival At the Intersection with or nearest Int&sectingstreet •