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t . t - City of Everett Use Only 1111111.11 r` TORT CLAIM FORM vocgi Rev.07/09 OCT 082013 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 ci ,eerk designated agent for the purpose of receiving claims. Claim forms 73 cannot be submitted electronically(via e-mail or fax). `�� i CCA0t3o0L15S° 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.,8 a.m.to 5 p.m., Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION: 1. Claimant's name: (Lt..1A t.4--- Ze'rel". ifi1&tom �965-.: Last name First Middle Date ofbirt (mm/dd/yyyy) 1 2. Current residential address: I f/l -7' ' `; s Gi-.. /-�,��Ag6, f e(��('P `i.)A- 91( J3 3. Mailing address (If different): 6 .. 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: - Z 1- 5 i .-4z-IV-- Home Cell Business 6. Claimant's e-mail address: /V INCIDENT INFORMATION: 7. Date of incident: 9 p 1 Time : ❑ a.m. p P . (check one) (mm/ d 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:: .��U�pli 3�‘, IA)0.SV� f i�r pt,f {�� State and county City,if applicable Place here occurre 10. If the incident occurred on a street or highway: / 4.1,1 <`f: . -. .Xe c 9e&n , "cf-e lly' 4. Name of street or highway At the intersection with or neast intersecting street Rev.07/09 / //