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, nitiovreitt7ryn 'IP TT ToRr CLAIM FORM SEP 19 21J13 Rev.07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), rry OF EV TT 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)` - t cannot be submitted electronically(via a-mall al.fax). 4.15aSe- PLEASE TYPE 9 PRINT CLOARLY : N 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 IN ORMATION: 1. Claimant's name: ( Tr;N Las.name first Middle Date of birth(mm/dd/YYYY) i 2. Current residential address: (j/r!'_ t/71957 i57 SF - - '/10 l-;v 'r-l.7T t,tsA /s 26 3. Mailing address(if different): 5/9 ut 6 ' 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: 6-17 5-- 4f-- t 501 4/49- 2.63- Zl-irf 4.1Z5-•341e("-6Z 6. Home Cell Business. 6. Claimant's e-mail address: l i,u c't Cieinlici ej 4oL- ,Co r INCIDENT INFORMATION: 7. Date of incident: 5?/ q/Zo/.3 Time : ( '30 0 a.m. Iiiip.m. (check one) (mm/dd/yyyy) 8.If the incident occurred over a period of time, date of first and last occurrences: from: Time: 0 am. 0 p.m.(check one) to Time: 0 a.m. 0 p.m.(check one) (mrn/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: 60c-1,5+i{'119[o iu ,. 540 I-Jo i'l t'S'ii ` (—w ve,/r / 5o-t rk Pot C c Pcec nr;7 State and county City,if applicable Place where occurred : 10,If the incident occurred on a street or highway: rVPr9ieiet1/41 11.)1 - rt/0n7h t36tAH0 lilc?,14/a /( 1`. crveel Name of street or highway At the intersection with or nearest intersecting street Rev.07/09