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Ell <br />Rev.07/09 <br />TORT CLAIM FORM <br />Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), <br />this form is for filing a tort claim against the City of Everett. Some of <br />the information requested on this form is required by RCW 4.96.020 <br />and may be subject to public disclosure. The City Clerk is the City's <br />designated agent for the purpose of receiving claims. Claim forms <br />cannot be submitted electronically (via e-mail or fax). <br />Mail or deliver original signed claim form to: <br />Business Hours: <br />Mon. — Fri., 8 a.m. to 5 p.m., Pacific Time <br />Clo.5ed on city holidays <br />CLAIMANT INFORMATION: <br />1. Claimant's name: <br />a 6r <br />Lastn me <br />2. Current residential address: <br />City of Everett Use Only <br />RECEIVED <br />OCT o 8 2013 <br />( OP EVTT <br />City Clerk CI tuJ4-"x�' .._.� . <br />`T3 <br />oC3oa��Rt7 <br />office of the City. Clerk <br />City of Eve IettI - <br />2930 Wetmore Ave., Ste. 1-A <br />Everett, W 98201 <br />41 <br />First f ( Middle Date of PIrth (mm/dd/yyyy) <br />3. Mailing address (if different): r2Fv `� <br />4. Residential address at the time of the Incident (if different from current address): <br />5. Claimant's telephone number: C� `" `� <br />Home Cell Business <br />6. Claimant's e-mail address <br />INCIDENT INFORMATION: y <br />7. Date of incident: —d C Time . ❑ a.m. ❑ p.m. (check one) <br />(mm/dd/yyyy) <br />8. If the incident occurred over a period of time, date of first and las occurrences: <br />from: Time: ❑ a.m. ❑ p.m. (check one) to . Time: ❑ a.m. Q p'.m. (check one) <br />(mm/dd/yyyy) / 'I (mm/dd/yyyy) <br />�711 f� 0$ , `'r <br />9. Loc-ation of Incident: i/ <br />State and county City, ifapplicable Place where occurred <br />10. If the Incident occurred on a street or highway: <br />Name ofsireett+orhJ/g9hway At the Otersectlon with or nearest intersechng street <br />Rev. 07t08 � •G�fiC ��' -` A Z4 <br />r, <br />