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Rt,crtivi) 4dge TORT CCAIM FORM SEP 0 3 7013 Rev.07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (12CW), CITY OF EVE ETT this form is for filing a tort claim against the City of Everett. Some of City Clerk the Information requested on this form is required by RCW 4.96:020 5i 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 x l .-j cannot be submitted electronically(via e-mail or fax) �`fl" � n;r:rs' LE ril 9 p. a{fmr .a �y!4�AIM nnm p Mail or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste.1.-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: + DeXni 1 L 4.2Jac>j/ccAE- Last name First Middle Date of birth(mm/dd/yyyy) 2. Current residential address: / - Z " "h s"-t SE Sr) d I /)--,15 t J A 3.Mailing address(If different): er. 0 4. Residential address at the time of the Incident(if different from current address): • 5.Claimant's telephone number: rc©l (4} 55;. '13•' 5361 (ya5) aq3- a Home r,Cell Business 6.Claimant's e-mail address: i e .Y— , g a Dr—O.it--)-11-; e r6--6 INCIDENT INFORMATION: 7. Date of incident: Time : U a.m. 0 p.m. (check one) (mm/dd/yyyy) 8.If the Incident occurred over a period of time date of first and last occurrences: from:031:?G)/) i3Time: 5-do Da,m.)p.m.(check one) to68/3 diyyya me: 5-=dd Ka.m. ©p.m.(check one) (mm/dd/yyyy) (mm/dy) &y 9. Location of incident: w > She) 1-1 O+-r J t U'e—r• Ha--pf es State and cdvnty City,ifappiiC7bie Place where occurred 10. If the incident occurred on a street or highway: Name of street orhlghway At the Intersection with or nearest intersecting street Rev.07109