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S i RocrivriD Ti TORT CLAIM FORM OCT 17 2013 Rev.07/09 • Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERET T this form is for filing a tort claim against the City of Everett. Some of City Cleric 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 ( r cannot be submitted electronically(via e-mail or fax). ti 01 ,50 H6 03 rki �j} �' T'-S�c-! \ _.. S`a� -L _ f -- ! tit- .. ,. Mall or deliver original signed claim form to: Office of the City Clerk City of Everett Business Flours: 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: Last name flat Middle Date of birth(mm/dd/yyyy) 2. Current residential address: 08'1-011 '- (.034P> LC i�,�+A .�.-► t>.� 9K oi'4 3.Mailing address(if different): / • 4. Residential address at the time of the incident(if.different from current address): • • 5. Claimant's telephone number: �2- L4 —�`it � Home Cell Business 6. Claimant's e-mail address: 1 'I4 i S e2 (144, e;e-� INCIDENT INFORMATION: 7. Date of incident: 14 1 Time : ❑a.m. 0 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: ❑a.m. ❑p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: I 2-ii C 11-eS ✓w; '� z (,t 4 241 State and county Qty,Ifappllcalile Place 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 1