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City of Everett Use Only I/4P .44;iTORT CLAIM FORM RECEIVED Rev.07/09 OCT 0 8 2013 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), this form is for filing a tort claim against the City of Everett. Some of CITY OF EVERETT the information requested on this form is required by RCW 4.96.020 � , and may be subject to public disclosure. The City Clerk is the City's City Clerk c designated agent for the purpose of receiving claims. Claim forms 1)an — \ cannot be submitted electronically(via e-mail or fax). G-ca01300 416) PLEASE TYPE Oit 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: 514 i(eibin/ Courneo 63 Jo 4//co-7 Last name First Middle ' 1 Date of birth(mm/dd/yyyy) 2. Current residential address: 111/ 617 Tti <7, 'E EvFe rT T U JA '1 8 207) A rr, /2 3. Mailing address (if different): 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: (360) -73 - 6'6 Horse Cell 1 Business 6. Claimant's e-mail address: ie'rkVa 'er)J' ' O rOL cc) t 4 c ,(I e INCIDENT INFORMATION: , toff. 7. Date of incident: O2/2 i/2O1 , Time : 6 fa° ❑ a.m. 1Kp.m. (check one) (mm/dd/yyyy) 8. If the incid nt oc urred over a period of time,date of first and last occurrences: from: 07 ;Zit 2t jne 6 n..00 ❑a.m. IgLp.m. (check one) toMOSAYr Time: ❑a.m. ❑p.m. (check one) (mm/dd/yyyy) '•( (mm/dd/yyyy) w 9. Location of incident: 4i4110G7.TM <Ivo 1-lonl4fl tJrI '1-1- - elk'Etfc) Amin t"'�.E2 5 State and county City, if applkable Place 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 //3