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City of Everett Use Only 11011111;111114 RECEIVE;1: 1CLAIM FORM Tl?RT OCT 08 2013 Rev.07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETT 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 Clerk and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No. designated agent for the purpose of receiving claims. Claim forms p,Q8 I -- cannot be submitted electronically(via e-mail or fax). 6-Co20 i 30045q /��;y�ca p �['� ��s��,�s t:,st. ��y. �'�;��+�,�� it- iE PCO-R PRiNTt\+L.�4^lam hi-fi=.= »�:�: -a 'La_c3F -iffi. .ia. n EiSt_. +�8�_.�� • Mall 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 S p.m.,Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION: 1.Claimant's name: Last name U First Middle Date of birth (min/army) 2.Current residential address: !' LI 7 �-,'d- SE A I Fyere* dell' I .24 3. Mailing address(if different): 4. Residential address at the time of the incident(if different from current address): 5.Claimant's telephone number: ( 12 ) i'?_6116 Home Cell Business 6. Claimant's e-mail address: INCIDENT INFORMATION: 7. Date of incident: . lime me: 5 e�6 El a.m. l p.m. (check one) fmm/dd/fy) 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: p a.m. 0 p.m.(check one) (mm/dd/yyyy) (mm/dd/yyW) q 9. Location of incident: �. - n t'r _ �-1/eie �-,� 1/ar/xfec'I/7 (4:004- State an county City,if applicable Place wh r occurred 10. If the incident occurred on a street orhighway: ? az) akyAke.. ackf r 11. 4P ►�Veite/� S•kn vi Oi>iRS �`� , �d!- ameofstreetorhghwpy ,A^ttheIntersectionwit or nearest intersecting street Rev.07/09 �/ dt r) i ai.W/�-r'(y( JwJ/.