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f R I,/� f 7v` {, City of Everett Use Only 'IP 000411111 R ED n TORT CLAIM FORM SEP 16 2U13 Rev.07/09 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 City Clerk 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 No. designated agent for the purpose of receiving claims. Claim forms J) / ,,3 cannot be submitted electronically(via e-mail or fax), &Caoi3o0`IS QLo iitatEt Y—0 i OR=I'RI IT7tt ,RLY_IN lmc = 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'st' name: Las na e First Middle Date of birth(mm/dd/yyyy) 2.Current residential address: 704 4t firer 1'". 3.Mailing address(if different): r e 4. Residential address at the time of the incident(if different from current address): r. „' 5.Claimant's telephone number: til- ' d7._j` Hor�e �/ �,,c Cell Business 6.Claimant's e-mail address: Ifa/ t4fl LZ2 k! TI .ohia:t..eoiv, ,INCIDENT INFORMATION:: 7. Date of incident: /l/�10/3 Time: • ' v Ili a.m. td p.m. (check one) (mm/dd/w ) >'?' i iSGr 8.If the Incident occurred,over a period of time,date,of first and last occurrences: from: Time: ❑a.m. ❑p.m.(check one) to Time: ❑a.m. 0 p.m.(check one) (ntm/dd/yyyy) / /� / / (mm/dd/yyyy) 9. Location of incident: N 1f�f'?d7/1l'i9lS`,�` fI/!�t':°if 6 Lawn'I/>', %:;ii/ State an county City,if applicable Place where occurred 10.If the Incident occurred on a street or highway: Name ofstreet or h&hway At the intersection with or nearest intersecting street Rev.07/09 t/