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F , City of Everett Use Only !!!!!!!!!!!b RECEIVED TORT CLAIM FORM SEP 19 2013 Rev.OT/Q9 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETT this form is for filing a tort claim against the City of Everett. Some of Cl Clerk the information requested on this form Is required by RCW 4.96.020 bJ 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 i t I cannot be submitted electronically('via e-mail or fax). % 624 PLEASE TYPE Olt PRINTCLEARLY'ININK 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 p.m.,Pacific Time Everett,WA 98201, Closed on city holidays CLAIMANT INFORMATION: 1,Claimant's name: rc,Ctt.h fL�IM �5 4( S 6,Gj , ©SAV7/ Q5/l Last nairf i=lrst Middle Date of bath mm/dd/yyyy 2.Current residential address: Lit litTi.1)cud_ h l t)A ?J 2' 3. Mailing address(if different): 4. Residential,address at the time of the incident(if different from current address): 5.Claimant's telephone number: Gl(n. l Home Cell Business 6.Claimant's e-mail address: Gilt? t;a.c i, e. (0.). / ii/Mal/. U'd> INCIDENT INFORMATION: 7.Date of Incident: ' ,P9/.20/3 Time: 6: C�C3 0 a.m. IN p.m. (check one) (mmjdd/YYYy) 8.If the incident occurred over a period of time,date of first and last occurrences: from: Time: Q a.m. Cl p.m.(check one) to Time _ —0 a.m. El p.m.(check one) (mm/dd/yyyy) (rrrm/dd/yyyy) 9.Location of incident: � It 5l1iti�jfd t� Oh, g/eee7f c2`i'O 66. //n (Ict ed • r/e- State and cocifity City,Ifapplicable Place where occurred 10. If the Incident occurred on a street or highway: Name of street or highway Attire fntersecelan with or nearestIntersecting sheet 2ev.;07/09 7/