Marysville School District Standard Tort Claim Form Packet Page 3
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5STANDARD TORT CLAIM FORM
Pursuant to Chapter 4.92 RCW, this form is for filing a tort claim
For Official Use Only
against Marysville School District No. 25. Some of the information
requested on this form is required by RCW 4.92.100 and may be
subject to public disclosure. Pursuant to the law, Standard Tort Claim
forms cannot be submitted electronically (neither email nor fax).
PLEASE TYPE OR PRINT CLEARLY IN INK
Mail or deliver
Marysville School District No. 25
original claim to:
Attn: Office of Superintendent
th
4220 80
St NE
Marysville WA 98270
Business Hours: Monday – Friday 7:30 am – 4:30 pm
/
Closed on weekends and District holidays
CLAIMANT INFORMATION
1. Claimant’s Name
______
Last Name
First
Middle
Date of Birth (mm/dd/yyyy)
2. Current Residential Address:
3. Mailing Address (if different)
4. Residential Address at the time of the incident (if different from current address):
5. Claimant’s Daytime Telephone Number
Home
Business
6. Claimant’s Email Address:
__________________________
INCIDENT INFORMATION
7. Date of the Incident:
Time:
am
pm
8. If the incident occurred over a period of time, list date of first and last occurrences:
FROM
am pm
TO
am pm
Date
Time
Date
Time
9. Location of Incident:
State and County
City, if applicable
Place where occurred
10. If the incident occurred on a street or highway:
Name of street/highway
Milepost Number
At the intersection or, or nearest
Intersecting street
Rev 8/21/15
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