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EV. TORT CLAIM FORM OCT 0 7 2013 Roe.07/09 _ CITY OF EVERETT 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 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' city Clerk Claim No. designated agent for the purpose of receiving claims, Claim forms — (32 cannot be submitted electronicaily('via e-inallorfox). Gtao t'3 poq57.5 .�id 4:ok a 4ys��pj�/�� i i �ti.M 11�?�),,.v3\�t _ I \� I ;r-�t \� a 1 Z h` `'�� _�'t Rti F.11iG?�-ftT � � x� ��.t!�.lsY.•.nS��hLlr ��-.�.�...L%� 4ti5�..�z..V. ':ki°�a...��'. 4.._.�s,..�..V.. _�1.i,.. . .�V_ Mail or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2030 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: __ Last name— First Middle Date oofb! t(m dd/yyyy) 2.Current residential address: L1635- -5c414r-ST AV 6 (=v-t.7T"r IVA C/A-7-0Y 3.Mailing address(if different): 4.Residential address at the time of the incident(if different from current address): 5.Claimant's telephone number: '2. -- Sfk- ir7I 'Z- 'c -3C -stici r Home all 8u ess 6.Claimants e-mail address: eictvt4 e.,jie4-[ sG,.r-r-ec" 40,...ecti.vf3_ cso-r --',z- ageteAtwittlY302 f} ,� INCIDENT INFORMATION: 7.Date of incident: Time: -: ❑a.m. 0 p.m. (check one) (mm/ddiyyyy) 8.If the incid t e erred ever a period of time,date of first and last oc rre ces: from: c-19 t'' icv Time: t xk,txc:1 pram. 0 p.m,(check one) to 619/(/?Ae/Time: El a.m. ❑p.m,(check one) (mrolddlyyyy) (mm/dd/Yyyy) 9.Location of Incident: L AAL r,.r(Pod .cvo lusts 4 c v e•`iT— `'C 3s s -�sr s r 4' i. r7— Stale and county t ay,if Place witete occuned 10.If the Incident occurred on a street or highway: Name of street or highway At the Intersection with ornearestintersedingstreet Rev.07/09 I