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J w, City of Everett Use Only 0/1:4 rr TORT CLAIM FORM WED Rev.07/09 OCT 08 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVE TT 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 4.96.020r� Clerk and may be subject to public disclosure. The City Clerk is the City's City Clerk ai o. designated agent for the purpose of receiving claims. Claim forms p D.a - - cannot be submitted electronically(via e-mail or fax). G-Ca►o t 30°416 $� 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: 441`lr b gcyic0,1 cl Ve it rr ``-/o Co Last name First Middle Date of birth(mm/dd/yyyy) 2. Current residential address: t I ( (" �17 54) S, . ,K M ue (.3 , 722a3 3. Mailing address (if different): 4. Residential address at the time of the incident(if different from current address): 1 t-t 41 C -Iti S. E L=UFire *r t,. 4 98,E o ' 5. Claimant's telephone number: 4,2 - 3,2 7- 6 /,S/ Home Cell Business 6. Claimant's e-mail address: INCIDENT INFORMATION: 7. Date of incident: 2 q ( 3 Time : 5- :. /S ❑ a.m. 211 p.m. (check one) (rnm/ddhyyy). 8.If the incident occurred over a period of time, date of first and last occurrences: from: Time: ❑a.m. ❑p.m. (check one) to Time: ❑a.m. ❑ p.m. (check one) (mm/dd/yyyy) 1/ (mm/dd/yyyy.)) 9.Location of incident: WA', $' 1 C}hoitii S4 hut?tr of (t,& ap i e&,, State and county City,if applicable Plad 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.07/09 tl 1 //