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City eip RE . . vat JD . _ Tr TORT CLAIM FORM OCT 0 4 2013 Rev,07/09 CITY OF EVERETT' Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), 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 f), tut -- k)`' canrrotba submitted electronically(via a-mail or fax), f Mall 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: al)1' c Pry tAdiu,(N 00 t6� I lasrri me ,- ; _.4..: frt�t--- . . - -,—:/firfdie- .:; :.Date bomb! (ligiva orf M- _ 2. Current residential address: 1'1' L.AU12 I L I012-aY i I.V I C i .IA . 1 M2tb( 3. Mailing address(if different): 4. Residential address at the time of the Incident(if different from current address): 5. Claimant's telephone number: it;.2tY2.6,1 0i 426 of .2*'.'2oQ!3, Home cell , Business 6. Claimant's e-mail address: ( 'r< (L('rl�n (� (OL Lir4 7 U�6t' Cz-M r coke INCIDENT INFORMATION: 7. Date of Incident: 6iital Ilaiv) Time : tv%j ` O U a.m. p,m. (check one) 1i(€nm/d /yyYy) 8. If the incident occurred over a period of time,date of first and last occurrences: from: Time: Cl a.m. 0 p.m.(check one) to Time: 0 a.m. 0 p.m.(check One) (mm/dd/yyyy) (mm/dd/yyyy) 9, Location of incident: 444 is 1M01-IOM14+ rzwra 1,24 l>Aogi, op-ive. State and county City,Ifapi l able- P/ace where occurred 10. If the incident occurred on a street or highway: Name of street or highway At the intersection with or nearest Intersecting street Rev.07/09 ciD 1