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Cl 0 RgCEIV°BD ir TORT CLAIM FORM aC► 2 3. 2013 Rev.07/09 CITY OF EVERETT Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), City Clerk 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 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 1-7 1 — 1 i cannot be submitted electronically(via e-mail or fax). Gj ti 3 p 0`'f(6O1 PLEASic-TYPE OR Pl<tINT C[:EARLY::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 na Last name First " Ali dle Date of birth mm/dd/yyyy) 11�`»_�.. � _.�,,_ •.: .o.. .atz7r{ti7f iti..A 2. Current residential address' .110L.I•Ew ., �:.,. .�-- �e�tnn■_ �—• 3. Mailing address (if different): Pt .} '� a . _ RA 1 0 :4 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: S) 91.3Ci ,, Home Cell Business 6. Claimant's e-mail address: Y't�`j ''1otC, XNCIDENT INFORMATION: '7. Date of incident: /2.C1// 2O\2 Time : (4111.:-Uks) El a.m. Xp.m. (check one) (mm/dd/yyyy) 8. If the incident occurred over a period of time, date of first and last occurrences: from: Time: l]a.m. 0 p.m.(check one) to Time: 0 a.m. 0 p.m. (check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: 1-6'01441 State and county City,Ifapp applicable e wh e 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