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14. Desc90"'al"t" <br />be the damages or injuries 'which you sustained as a result of the incident: <br />.r'�a".S. W�n�w ❑arcs ser. NVQA�•,.w L>Oov-. `�✓1 <br />C7 r OuJ f t►,4 �c] &;o C�V I T•,% I I 8 �d�3� S ��S �7c� C) Rah ��•-Y, <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />(: Se xtP�. f = 89 z.08 p rA 100, 0 _ <br />UO"tLwtNofl- 4 1o�Lq. O �;-x'00 `'�AL->okos�43 <br />16. How did you identify the County as the parry responsible for your damage? <br />COMA J SMe'L-J ✓enaa un.1 <br />IT List the names and addresses of all witnesses to the incident: <br />N en[ <br />18. Are you covered by insurance? Ye5 If yes, who is your insurance agent/carrier? <br />f nr 2G M oST" �nS�t�ANL E � �ou� <br />Dated this _ Day of �� 0 _, 20�. <br />Siana of C ant <br />Subscribed and sworn (affirmed) to before me this day of (-" ELV4 u/ , 2019 <br />NOWY PWAC <br />Still d WOMMPI <br />fift T Uri <br />My Appolnlmrdt EKOq JUN K MO <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 912012 <br />Notary Public <br />in and for the State of Washington <br />Residing at <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 912012 <br />