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I City of Everett Use Only #11, iiih%°-1°Isg RECEIVED vdi; TORT CLAIM FORM Rev.07/09 SEP 0 5 2013 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 the information requested on this form is required by RCW 4.96.020 Citi Clerk and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim le. , designated agent for the purpose of receiving claims. Claim forms •P l,(4 - cannot be submitted electronically(via email or fax). P 'EAS PE'OR I T::CLfE Y : .. . ..... .. ...... ....... .. . . . .. . . ........ . ... . . . ... ..... .. 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: I. Claimant's name: \34eeE 31A) \311/,plcy - 3 - )(v. Last name First ! Middle Date of birth(mm/dd/yyyy) 2.Current residential address: [P/ 7 7 Oh' f 16 �/3ilCG'�fEY/c�_.�f15 fgz.675 3. Mailing address(if different): \5f/ye 4. Residential address at the time of the incident(if different from current address): 0I2/ LoAtome,0 1}vg. pia 9B I 5. Claimant's telephone number:�j'f�.5 'q22 fOD2.. TES ' �/ .rj 'Jt2,.41 t5Og•22rCg Herne.aace. £e# /H Business 6. Claimant's e-mail address:kh I 5/Sot tSeAld_Li ,A1Ae2/1lg. . CdNl INCIDENT INFORMATION: 7. Date of incident: /01fL �I 2 OLD Time : 'e.3D ❑a.m. {,p.m. (check one) (mm/dd/yyyy) 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: 0 a.m. ❑p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: L512/ X D / L) 111d6 �1/'j2C-77—' 9 -e J State and county City,If applicable Place where occurred 10. If the Incident occurred on a street or highway: L/fit) ,4, L 2A2Z Name of street or highway At the intersection with or nearest intersecting street Rev.07/09