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. ..., City of Everett Use Only RECEIVED Vrr TORT CLAIM FORM OCT 2 5 2013 Rev.07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCVV), crry OF EVERETT 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 f)(. /46 —6 cannot be submitted electronically(via e-mail or fax). 6, . loi Ga'caoo 6/6 r ir 4114,EAti-f070:4‘,0kAkiritt-titiikiNi--theiNk • - , - -,„ . ,,_ , - -- . - -- - ,, . . - •, 7, - ';: 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: gus itei 27 7?7y , i. ic/4 c s 40 r-N 7/11ES(../c------- / . Last name_ First Middle Date of birth( in/cid/my) 2. Current residential address: / ) 1 i 7 3 r c / rA Z 3. Mailing address(if different): . 4. Residential address at the time of the incident(if different from current address): • 5. Claimant's telephone number: 7'25" q6...? Home , , 4 Cell Business 6. Claimant's e-mail address: AiA INCIDENT INFORMATION: / 1-.1 7 3 7. Date of incident: _ .S. .11-t.Time: Cli__1 a.m. p.m, (check one) (mmidcli ) 8.If the incident occurred over a period of time, date of first and last occurrences: from: Time: 0 a.m. Li p.m.(check one) to Time: 0 a.m. 0 p.m.(check one) (rern/dd/yyyy) (mm!ddJyyyy - 9, Location of incident ,;.,- GO YQ.,„ k,ifikA-Q____ State and county City,"applicable Place where occurred 10. If the incident occurred on a street or highway:. ,.. Name of street or highway At the intersection with o r nearest intersecting street Rev.07/09 )b '