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ten(` _ I(. City of Everett Use Only eP,"0/- REC RECEIVED rr TORT CLAIM FORM {��9' r� Rev,07/09 SE 1 r 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVE ET i' 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 � `k and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim N . designated agent for the purpose of receiving claims. Claim forms `i } )U� ;'` - cannot be submitted electronically(via e-mail orfax). f t CTe ► 004-LSo Mail or deliver original signed claim form to: Office of the City Cleric 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: N,an O i �5 - A/d Cast ne FirsttU Middle Date of birth(mm/dd/yiyy) 2. Current residential address: ,(2)(,,...1 6h01re- AV enu fl E-'te 9�1033 3.Mailing address(if different): 5 et. tt 4.Residential address at the time of the Incident(if different from current address): 5.Claimant's telephone number: f 'a5 34712 AS) l-S 3So b 6 Homen 4,, Cell Business 6.,Claimant's e-mail address: ne d al L" 4QY71 I INCIDENT INFORMATION: (0:0 P/\ /too Q►'lu 7.Date of incident: 8$ aq 2 0 -(Ina 09-- OS'Tme 3. ' ❑a.m. 0 p.m. (check one) (mm/dd/yyyy) • 8.If the Incident occurred over a period of time,date of first and last occurrences: from: .'-0.9.{3'Time („i 21t> 0 a.m.` I p.m.(i on) to ' 13 Time:. 0.a.m. l .m.(check one) (mm/dd/yyyy) (roc( (mm/dd/yyyy) (A I ti nlC)rn t 9 Location of incident: "'MI IDQ r;1 -` _kit) State And county City,if applicable Place where occurred 10. If the incident occurred on a street or highway: Name of street or highway At the intersection with or nearest intersecting street Rev.07109`=