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City of Everett Use Only • #111P.eimkg 4,44,6er' TORT CLAIM FORM RECEIVED Rev.07/09 • Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), OCT 08 2013 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 CITY 1W EVERETT and may be subject to public disclosure. The City Clerk is the City's City Clerk Cl 14No. designated agent for the purpose of receiving claims. Claim forms Ci C k cannot be submitted electronically(via e-mail or fax). i , 7),A2) - GC42013004167?- PLEASETYPE OR.PRINTCLEARLY 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: Last name First Middle Date of birth(mm/dd/yyyy) 2. Current residential address: / I ) ) 1—n 4\ 54# 5'' Av,4 /4.).3 eve,,- ` ' LA 1 1?ab3 3. Mailing address (if different): 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: 5-3 17 5670 I Home Cell Business 6. Claimant's e-mail address: O re/t, 6r-U.it4c J ej 0 3 1.( rh yv INCIDENT INFORMATION: 7. Date of incident: ) 3-/a `l /R D 3 Time : SC) 6 ❑ a.m. 1 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: ❑a.m. 0 p.m. (check one) to Time: ❑a.m.- ❑p.m. (check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: ,iA 5mi„Dm,{S�r�, E'U-r2,�- `''�' A 2(4f,1.ev4 State and county City,"applicable Placb 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 (7.?