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mom R&HVED 000)4,„LiFt___ 4041 rr TORT CLAIM FORM SAP 0 6 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 Cl 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. r designated agent for the purpose of receiving claims. Claim forms ) 100 ei, l cannot be submitted electronically(via e-mail or fax). t reVOIN a > Ya Mall or deliver originai signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste.1-A Mona-Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION:; 1.Claimant's name: iYpis%2 a, A.V ( J 08 -0 ' - ! 9.33 Last name first t� Middle Date of birth(mm/dd/yyyy) 2.Current residential address: LI ( (.4r^•-1 iZ() E-- FELL- , CV 5)(2,dl 3.Mailing address(if different): A C 4.Residential address at the time of the incident(If different from current address): ,S E, 5.Claimant's telephone number: 5 y --/°/O2 atx -93 o-f 7 l Hoe Cell Business 6.Claimant's a-mail address: C. LA( -ICE LE &MA I C_ C ()iv! INCIDENT INFORMATION;. 7.Date of incident: 9 —6 — 1 3 lime: cvZ,`00 A.m. Li p.m. (check one) ( /dd/vyvv) 8.If the incident occurred over a period of time,date of first and last occurrences: from: Time: 0 a.m. 0 p.m.(check one) to Time: 0 a.m. iJ p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9.Location of incident: W A SAW/40y141314 - V e TT W I Lii2 UGC E rt"2,I State and county City,Ifapplicable Place where occurred 10.If the incident occurred on a street or highway: _Erivr-i- . ¢mod I Nerve of street or highway At the intersection wilt,or nea est Intersecting street Roy.07109 '