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0' / City of Everett Use Only 0.44°1 °II /11PIP:"11. 400000.04 Cr RE LIVE dTr TORT CLAIM FORM wItf Rev.07/09 '.)LP 1 9 7"1 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF PVER; •r'? 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 ON 0. • ', and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No. designated agent far the purpose of receiving claims. Claim forms D I i/6) i -- 1 .3 cannot be submitted electronically(via e-mail or fax). 6CO 1 100 ki6 a3 pLEAscriv:iittkpRINtiatAttccwiNK ' , .,- , • ,, -,- --,'.. ' - :::' , . . ' ',-,-, , ,, , ., ', - ,, 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: I. Claimant's name: 5 A N ?>tgG- MiSTY 2-ti A)Af I O'7-'30-1ig5 last name First Middle Date of birth(mmfdd/WYY) 2. Current residential address: ill/ 4-0.7-11 SI-. .E. Ptpl-A i -.'ile-re)(4"" abgi cp&(-)3 3. Mailing address(if different): S Pr(Y\e- cA s ck bov e- 4. Residential address at the time of the incident(if different from current address): Sa_AML. ,CtS Mk>ov , 5. Claimant's telephone number: //,-25-c)Sq-56,53c) 205-7q 1-89 gq ,..------------- H ope Cell - Business 6. Claimant's e-mail address: 3171,:) 1,-yk- V\a kj e- o iv INCIDENT INFORMATION: 7:301,901 7, Date of incident: 00-aq-aOkS Time : 3:wpm 0 a.m. igi p.m. (check one) 01m/cid/WM 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 am. Ci p.m.(check one) (mm/dd/yyyy) (mmldd/yyyy) 9. Location of incident: C,00, \AA.vtIon ii SirtOooVictriV5 , -'-'-i/le-fv- Eite-roAt-e.fat Ale,rot-m41-"g State and c nty ' City,ir appkable PlaCe where cc tared 10. If the incident occurred on a street or highway: N- A Name of street or highway At the intersection with or nearest intersecting street Rev.07/09 E/2)