Laserfiche WebLink
F- <br />8o2498/2°17 @2:3"7 PM pig;Rfsof t€01702080017 <br />i,ill,i]T,hal,iiiii[ii!iiifffiiiiiiiii(iiiiiiiiii]iiili!Iiiiiiiiiilll!l!'`!']'!!! <br />jROsEeuroR <br />Prose8u€® rs Cffiee <br />FEB fl 4 2®i7 <br />Civil Divisl®m <br />tT:Hrf <br />comassloNERs|±4_i <br />DEPA:i.TT.J:I,`JT#yi'=\`±=. <br />I,\~`' Tut If`--. L> = 1-. <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />:o°5u#5A|dv£::;uitel05 <br />Ellensburg, WA 98926 <br />509-962-7504 <br />Instructions: <br />Please read the entire form before completion. Fill out each question as completely as possible, <br />to the best of your ability. Do not hesitate to use the back side of this fom if you need more than <br />the space provided. An incomplete response may delay the processing of your claim. <br />1. Name (Including spouse, if married):i_B±±__LceT|f± <br />Phone (hTome):4±1ft__lEi <br />Address (include former address if at present address for less than 6 months): <br />| IC) S~oQutLch /G DR. €noQu^ru~ii£_ f:4€J. ut 98o€8' <br />Physical <br />©to\ BBldcMltr Rd El(ErJSBuf26r wh 96¥26 <br />Mailing <br />DateofBirth: 9~/~G/ <br />5. Date and Time of lncident:r tc)- 7Lo\ <br />Location of Incident: <br />7`o sr`c>QUAL vw`Er <br />1of3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012