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City of Everett UseT I "'Only • .111 I LLI V Tr TORT CLAIM FORM OCT 2 4 2013 Rev.07/09 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 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 Clq Claim No.— / designated agent for the purpose of receiving claims. Claim forms "t (3 cannot be submitted electronically(via e-mail or fax). f9 C oLO(300 S.l6!fo PLEASE TYPE OR PRINT CLEARLY EIN 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 INFORMATION: 1. Claimant's name: • CoMPONE,n7i- CO:WEFTS 1 INC, Last name First Middle Date of birth(mm/dd/yyyy) 2. Current residential address: 3025:) PINe. S Ct" ' l/ e('t-' i_Ji `682O I 3. Mailing address(if different): 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: • 425- 1-G323 .2s8-k64S Home Cell Business 6. Claimant's e-mail address: w1i SKY-ec c ri Airbii s7j czwcE`lors►7VFrT INCIDENT INFORMATION: 7. Date of incident: AUC�t.)ST 2'r 2bt1 Time : G:6D ❑a.m. L�J 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. 0 p.m.(check one) to Time: ❑a.m. ❑p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: WA CAkionw ts' GA- car F9G4u-rr State and county City,if applicable 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 I