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y t City of Everett Ueo Only0441iiirliP—A RECEIVED ''�w TORT CLAIM FORM Rev.07/09 OCT 03 2013 Pursuant to Chapter 4.96 of the.Revised Code of Washington(RCW), CITY OF v v ET, this form is for filing a tort claim against the City of Everett. Some of 4 the information requested on this form is required by RCW 4.96.020 { r Clerk and may be; subject to public disclosure. The City Clerk Is the City's City Clerk cia • designated agent for the purpose of receiving claims. Claim forms CI --- 1 cannot besubm fitted eiectronicaily(via e-mail or fax) l 9-0130 GI4.671 PLEASE TYPE OR PRINT CLEARLY IN INK 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.,S a.m.to 5 p.m.,Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION: 1.Claimant's name 03 —2a._ f%l- Last name First Middle Date of blrth(mm/dd/Yyyy) 2.Current residential address: 0 i Z Z 5 A.t) -i.(P • 3.Mailing address(if different): ,i,rri(-a. 4.Residential address at the time of the incident(if different from current address): 1 5.Claimant's telephone number: 1425-513. 7- 1175-- 47-4 432— Horne Cell Business 6.claimant's e-mail address: mil}-itk t L. Epp toty36 a& y/IA-;t'-aue r ' xNCIDENT INFORMATION: 7.Date of incident: £) .05143 _ Time: 5100 0 a.m. 14.m. (check one) (inm/dd/yyyy) 8.If the incident occurred over a period of time,date of first and last occurrences: l from: Time: 0 a.m. 0 p.m.(check one) to Time: D a.m. 0 p.m.(check one) 1 (mm/dd/yyyy) (mm/dd/YYYf') 9. Location of incident; • 6n r /47.41USIA . 'ZiGk -• PI r2 _ t�� T3 Ste and county taty,If applicable Pia where occurred 10.If the incident occurred on a street or highway: Name ofa-net or highway At thelntersection with or nearestintetsecdngstreet Rov.07109