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• .�) - �,Q , iI L— I/ 2013-09-19 15:07 EVERGREEN 4252570795>) P3111 City or EverREcEett Use Only IVED 41,-, 7 �, - A i .4401TART CLAIM M FORM SEP 2 4 1013 Rev.07/0CITY OF 9 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), ' �VE ETT _ this form is for filing a tort claim against the City of Everett, Some of City Clerk 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 Claim No. designated agent for the purpose of receiving claims. Claim forms ) t 1 q cannot be submitted electronically(via e-mail or fax), Q 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.,B a.m.to 5 p.m.,Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION: 1. Claimant's name: tiic( ict", l�C�L..I�G Last name First Middle Pat ofbirth(rnm/dd/yyyy) 2.Current residential address: 1,j 1 41,, #'~ A 1/4 'E E1' . q, 3 3.Mailing address(if different): /a Z C. i J C S i h b- P b• t` J"7r Oi 734 G/ 4. Residential address at the time of the incident(if different from current address): 5.Claimant's telephone number: 6tZ- -75 v"7/Zt Home Cell Business 6.Claimant's e-mail address: P A t. w e t..1//, bpi l vi Vc414. wt . INCIDENT INFORMATION: "i 7.Date of incident: V►St�4` 11��1 Time: �f ❑a.m, 'p.m. (check one) (mmfddiyyyy). 8.If the incident occurred over a period of time,date of first and last occurrences: from: Time: U a.m. (1 p.m.(check one) to—.: Time: f a.m. 0 p.m.(cheek one) (mm/dd/yyyy): (mm/dd/yyyy); 9.Location of incident: Swvla vt.",cA C r A. E ver-ru- A < State and county City,If applicable Place wh occurred 10.If the incident occurred on a street or highway: Name of street or highway At the intersection with or nearest Intersect/lig Street Rev.07/09 rja