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RF er triY ED #01°P1'..-",„idigY TORT CLAIM FORM SEP 1. 3 2013 Rev.07/09 CITY OF:EVE ETT Pursuant to Chapter 4,96 of the Revised Code of Washington (RCW), City'Clerk this form Is for filing a tort claim against the City of Everett, Some of `J 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>I1o: I designated agent for the purpose of receiving claims, Claim forms ) I'' T2 - 1' cannot be submitted electronically(via e-mail or fax,), I t LAD • PLEASE f'TYPE cik PRINTc1 EARL`LY IN INK,a, ..,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: Ho ban er4 .i-1-1--e.re.3+-5 >,. c. Cfb s 116 ns l—bbc r) Last name first / Middle Date of birth(mm/dd/yyyy) 2.Current residential address: cP Ba 9' ISLA C 6 el— P\''e. 3, Mailing address(If-different): - 4, Residential address at the time of the incident(if different from current address): 5, Claimant's telephone number: LilA 5 3361 3(.>J + � Nome Cell Business 6, Claimant's e-mail address: S rl L jCLt 1.(=C:'61'3-f rvi C�. i-,C 6 fv-) Lt 11 01 rri ICI t i 5 C,Ce>C13+-Agc3-1-.CG/xl INCIDENT INFORMATION: Del 7.Date of incident: Time : ❑a.m, p.m. (check one) (mm/dd/yyyy) 8.If the Incident occurred over a period of time,date of first and last occurrences: from:C. 1a1t 1-/ i 0 a.m. f$p.m.(check one) to ?3).9Ig613•ime: f�'000 a.m. ,1.4.m.(check one) (mm/ddlyyyy) (mm/dd/yyyy) 9. Location of incident it) S n I7 tviy1; 1,i eve rep- v26,39 o2Ltc k2ir State and 6ounly City,if applicable Place where occurred 10. If the Incident occurred on a street or highway: f � tiKer C rrit r- ), Name of street or highway At the intersection with or nearest intersecting street Rev,07109