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City of Everett Use Only RECEIVED __ TORT CLAIM FORM Rev.07/09 SEP 17 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF wire ,ET 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 c ,`t� C1s 'J and may be subject to public disclosure. The City Clerk is the City's City Clerk o. designated agent for the purpose of receiving claims. Claim forms 9 1 — '` cannot be submitted electronically(via emall or fax). ,i' t .0LACto415 to 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.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201. Closed on city holidays CLAIMANT INFORMATION: 1. Claimant's name: • LasFname First Middle Date o>birth(mm/dd/yyyy) 2.Current residential address: ,,.. 1�� U)a(e1 Or. Uer 3.Mailing address(if different): 4.Residential address at the time of the incident(if different from current address): 5.Claimant's telephone number:2in-2)48—f1O 7 �ZS a GO 1I Z5- 1-ice(, Home Cell Business 6. Claimant's a-mail address: l�Mt f net- INCIDENT INFORMATION: 7.Date of incident: g/2-411 13 Time f).' El a.m. gp.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) (mrn/dd/yyyy) (mm/dd/yyyy) 9.Location of incident: WO .5h Dht) 5t,) Re( .1(I toctil6 Of,0_, State a)id county City,If applicable Place where occurred 10. If the incident occurred on a street or highway: sit) fir, t, be:Intersection e M .74ue . am o s or highway At the with or nearest Intersecting street Rev.07109