2920 RUCKER AVE HAIR FORCE 2022-05-31

447T TORT C% AIM ,BORN Rev.07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), this form is for filing a tort claim against the City of Everett, Some of 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 designated agent for the purpose of receiving claims. Clalm forms cannotbe submitted a%tronically (via a -mail or fax). City of Everett use Only R�cElvEn SEP 2 5 2013 City Cleric a1 r%No�f. -Ltt 5% -- t' 5 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 CI..AIMANT INFORMATION: 1. Claimant's name: ' "7 2- 1 Io t Lastname ff First Middle Date ofbM (mm/dd/yyyy) 2. Current residential address: U 0e- by r, F- V P_-re,*. 3. Mailing address (if different): 4. Residential address at the time of the incident Of different from current address): 5, Claimant's telephone number; L{ 5 254_ !tv'/Go I5 + -fib! d' hl �15q r7q l Home £31'1 r_ -Cell t`ailiP�. Ck�Usiness 6. Claimant's a -mail address: �? i-� r /'/rw-S `f- c2� C -, CrXz5 ./'I2 t_ ___......_...._._..._ . INCIDENT INFORMATION: 7. Date of Incident: 91l30A3 Time : �.n1� p.m, (check one) (mm/dd/YYYY) B. )f the lnclrlenoccurrecl over a period of time, date of first and last oc urr aces: from:/ sa 7+ Time: a}. p.m. (check one) to 9 73 7 Time: a.m. p.m (check one) (mm/dd/yyyy) ` "� (mm/dd/YYYY) 9. Location of Incident: W11F'5rtQtomi!&h1 Lyea-e- I 2`);24) l�ucl��.�•Frvc� fzcr%gyp, state and county Cty, if applicable Place where occarfed Sa. ti 10. If the Incident occurred on a street or highway. of street orhlghway Rev. 07/09 At the mtersedtlon wlth or nearestlnterseciing street