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i , ...-- i Crefrielf,1\0 Cil n TORT CLAIM FORM ro ' 1. . 2.a13 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 ofA 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 'Dago.- 13 cannot be submitted electronically(via e-mail or fax). t fr PLEASE TYPE OR PRINT CLEARLY IN INK 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 INFORMATJON: 1. Claimant's name: Last name first Middle Date of birth(mm/dd/yyyy) 2.Current residential address: ,//(,g 7/ /9e9a CAL/ J , 3. Mailing address(if different): �-. � i"� /74 �G� 7 , -'J 4. Residential address at the time of the incident(if different from current address): 5.Claimant's telephone number: 9 5 } 'i f.P.-, -) rr `' Home C l/ Business 6.Claimant's a-mall address: s 1� ,�2;1�/.1.(?:rG? /' ra is�}7lr. '" .A// / INCIDENT INFORMATION: ' J � -' l7 C� 7. Date of incident: / -5, , ,/ l Time:"7 El 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:I Time: 0 a.m. 0 On.(check one) to - Time: 0 a.m. 0 p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy 9. Location of Incident:� ., 4 -(1 S�bf1./1-- /7/f /jy i State and county City,Ifapp ticable : Place where occurred 10.If the Incident occurred on a street or highway:ur4 , Name of street or highway At the Intersection with or nearest Intersecting street Rev.07I09 //k ig