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) . . . • EvE e se 11 D Cf EvEI 04117"I 'TORT CLAM FORM OM' 2 2 2013 Rev.07/09 CITY OF EVERETT Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), City Clerk 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 4.96.020 and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim N . designated agent for the purpose of receiving claims. Cfaitn forms cannot be submitted electronically(via e-mail or fax). • • Ge go(30 )4/6/a itoss-titygnitommanew4-earmamegoetexewmilmlat-m-z72. 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: e.it) (a/ti /gig Last name First Middle Dat of Mb(mm/dd/yyyy) , 2.Current residential address: (.1"/001.0 Fi5&A74i" /3 3- SE 260V M D5 co.€ /V 4 .• 3.Mailing address(if different): SUJE Of../k/ .• 4.Residential address at the time of the Incident(if different from current address): 5.Claimant's telephone number: 4/6 (It 8' •/3/00 (44 •4't if • 3 fr• LIG o Hipp Business 6.Claimant's e-mail address: bw,.d 1".8 .INCIDENT INFORMATION: 7. Date of Incident: Scp4 20/ Time: LI a.m. 0 p.m. (check one) (rvo/dftyyy) 8.If the incident occurred over a period of time,date of first and last occurrences: from: Time; 0 a.m. 0 p.m.(check one) to 0 a.m. El p.m.(check one) (mm/dd/yyyy) (rnm/dd/yyyy) 9.Location of Incident: Sy) Co vii.4 e ve tc State and county ay,"applicable Mace where occurred 10.If the incident occurred on a street or highway: M p r ru../-A, 1?-9.1 ROI bioo(( Ave Etleteg WA- q5-2o3 \-)NarAe of sire&or hIghWay.) At the Intersection with or nearest intersecting street • Ftov.07/09 TTh /I, I/