Standard Tort Claim Form
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1
2STANDARD TORT CLAIM FORM
Pursuant to Chapter 4.96 RCW, this form is for filing a tort claim against the Lake Washington School District No.
414. Some of the information requested on this form is required by RCW 4.96.020 and may be subject to public
disclosure. Pursuant to the new law, Standard Tort Claim Forms cannot be submitted electronically (via email or
fax).
Mail or deliver original claim to:
Janene Fogard, Registered Agent
Lake Washington School District No. 414
th
Street Address:
16250 NE 74
Street
Redmond, WA 98052
Mailing Address:
PO Box 97039
Redmond, WA 98073
Monday – Friday: 7:30 a.m. – 4:30 p.m.
Business Hours:
Closed on weekends and official school holidays
CLAIMANT INFORMATION
Claimant’s name:
1.
_____________________________________________________________________________________________
Last name
First
Middle
Date of birth
2.
Current residential address:
________________________________________________________________
3.
Mailing address (if different): ________________________________________________________________
4.
Residential address at the time of the incident (if different from current address):
_____________________________________________________________________________________________
Claimant’s daytime telephone number: _________________________________________________________
5.
Home
Business
Claimant’s email address:
6.
________________________________________________________________
INCIDENT INFORMATION
7.
Date of the incident: ___________________
Time:
_______________ a.m./p.m. (circle one)
8.
If the incident occurred over a period of time, date of first and last occurrences:
from ___________ time:________ a.m./p.m. (circle one) to ___________ time:________ a.m./p.m. (circle one)
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 or highway
Milepost number
At the intersection with or
nearest intersecting street
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