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14. Describe the damages or injuries which you sustained as a result of the incident: <br />i0aYY1¢ 4, `!0 C O"'r, , MD Jul G a k , -- <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />16. How did you identify the County as the party responsible for your damage? <br />17. List the names and adds asses of all witnesses to the incident: <br />.5 -ee ���� PS i,W► J <br />18. Are you covered by insurance? Yf s If yes, who is your insurance agent/carrier? <br />,54-c,,vn , <br />Dated s Day of —J7O(iw ,', 2011 <br />Signature of Claimant <br />Subscribed and swom (affirmed) to before me this 1 day ofF` " 1 20 <br />Seal <br />n 0 r?-Mz Sri T:�Yl-b <br />Public in and for the State of Washington <br />ng at LJ -Pr <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />