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P � � o o r 311.36 <br />l <br />TORT CLAIM FORM <br />Rev. 07109 <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 submitteifetectronically(Wae-mail or fax). <br />R EK U V D <br />SEP 2 6 /2flI 3 <br />CITY OF(EVERETT <br />City Clerk <br />City Clerk Claim No. <br />PLEASE T Yt3i? OR PPiNT CkE-Afr;LY fN IIVK <br />Mail or deliver original signed claim form to Office of the City Clerk <br />City of Everett <br />Business Hours. 2980 Wetmore Ave., Ste. 1-A <br />Mona-- Fri,, 8 a.m to 5 p.m., Pacific Time Everett, WA 98201 <br />Closed on city holidays <br />CLAIMANT INFORMATION: <br />1. Claimant's name: <br />lastname Flrsf Middle Date ofWffi (mm/ddlyyyy) <br />2. Current residential address: <br />3. Meiling address (if different): — 'S # <br />4. Residential address at the time of the Incident (If different from current address): <br />S. Claimants telephone number: L <br />15�- o 73 - L 70 41 <br />Home Cell Buslness <br />6. Claimant's e-mail address <br />INCIDENT INFORMATION: <br />7. Hate of incident: I � � � -� � � Time: ❑ a.m. Rrp:m. (check one)' <br />Flop i (mm/dd/yM) <br />8. If the incident occurred over a period of time, date of first and last occurrences: - <br />from: Time: D a.m. Ap.m. (check one) to lime: ❑ a.m p.m. (check one)' <br />(mm/dd/riyy): (mm/ddlyyyy) <br />9. Location off ncident: W # � �? 1 ✓�� IV, <br />V S/v.a1�a6/h r �? r r /.� e <br />�'Yate and countk City, IfappllrablePlace where occurre <br />t <br />t <br />1p. If the incident occurred on a street or highway: <br />Is n. �b 5'r <br />Name ofstreet orh/yhway <br />Rev 47149' <br />Mon w/th or <br />C�2� <br />