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RECEIVED r—g- TORT CLAIi►9 FORM SEP Q 6 2013 Rev.07/09 CITY OF EVERETT Pursuant to Chapter 4.96 of the Revised Code of Washington (ROAD, this form is for filing a tort claim against the City of Everett, Some of City'_.I - 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 Gterk claim too. designated agent for the purpose of receiving claims. Claim forms 0) — 1 9 cannot be submitted electronically(via e-mail or fax). . PIIt � i6bTy� �+ �,+,�,n b ^.-_..:� y��y t St �t t -til a- 1\. -c c��.: .,� �..�,�� y1 �{P�� 00aVY F!s1.f,?c£iftN i�F?i,!7iT'�WataM!1.,Z?� il:,(s a 3 .lnri_.1 ` < . ;. . Mail or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste.i-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: 1�C00ie.sT2. DAV D - O /9 Last name first Middle Date of birth(mm/dd/yyyy), 2.Current residential address: 1 11J i-Oc-IC e r e6 L G- . triv r 2f�' DI 3.Mailing address(if different): .cam' 4,Residential address at the time of the incident(If different from current address): 5. Claimant's telephone number: E0-5"02 5$ l Ye.).9 d P -.39 '/7/ Home Cell Business 6.Claimant's e-mail address: GLA 2IC. L( e Z .Zer, xt) . G' ,INCIDENT INFORMATION: c 7.Date of incident 8 " j Time.: ln, 3 U El a.m.r8Kp.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: CI a.m. Li p.m.(check one) (mm/dd/yyyy) (mm/ddtyfNy) W s y W i 2oc-K-C 9.Location of incident: c�it�t�2�1/r+�i U �� l rt' �- r ELL �- Pev� I State and county City,lfapp//able Place where occurred 10.If the incident occurred on a str et or highway: Name ofstr or highway. At the intersection with or nearest Intersecting street Rev.07/09