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, City of Everett Use Only 'IP j m TORT CLAIM FORM 4116;VI Rev.07/09 NOV 1 8 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), ` � lg ,ITCR ' T 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 4.06.020 �''iror Cleg° and may be subject to public disclosure. The City Clerk is the City's City Cleric ClamiNa. designated agent for the purpose of receiving claims. Claim forms — (% 7 cannot be submitted electronically(via e-mail or fax). t takeriyar ki t k iT ke. . ft W A1 'f .64t M ' t t 1 e i 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 CLAIMANT INFORMATION: 1. Claimant's name: C(1)49Pfl1 �'/ i'f fni c k A n(Alq l ri • O,.57/1Y// 9d/.c Last name first Middle � Date of birth( m/dd/yyyy) 2.Current residential address: ' // c91 i--P_h A Irfrt.. .*, £ ei-6 J,�' ✓� .,) P75'a 0 / 3. Mailing address(if different): 4.Residential address at the time of the incident(if different from current address): 5,claimant's telephone number: d/a..s-r .S"'-OAS' Home C!1 Business 6.Claimant's e-mail address: pc?t cb/e..'z?//d C t fry r: . h 6 INCIDENT INFORMATION : 7.Date of incident: Ct FS'/R,9/0.. Gi/: Time : 9'0-0 0i ❑a.m. g: p,m. (check one) (mm/dd/yyyy) 8.If the incident occurred over a period of time,date of first and last occurrences: from: Time: 0 a.m. 0 p.m.(check one) to Time: 0 a.m. 0 p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) We �// e r .l 9.Location of incident: Wea x AAA t ill s r'}t1/)d h'}1-rh1 ."tom 4`- !/ 1 1/ 4,-&c P,h r�' h u p. State and'&untyi City,If applicable Place where occurred 10.,If the incident occurred on a street or highway: Weth''eh Avey,u « If/meat street orhighway At the Intersection with or nearest rntersectfigstreet Rev.07/09 \, I // )