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03/06/2017 11:19:05 AM 201703060010 <br />$0.0© Pa9e:i of 8 <br />KittmtaCAgnty <br />sGRudito�is/mise KGPROS <br />1111111114111111111111!11111111111111111 II1111411111111111 IS 1111111111111 <br />I'ROSidPA <br />CON IISSIONERS <br />DEPARTMENT <br />INSURANCE - <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5h Ave, Suite 105 <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 form if you need more than <br />the space provided. An incomplete response may delay the processing of your claim. <br />Name (Including spouse, if married): <br />'RoAfeq ( I' kRe- <br />S;)Nwovn Ci�5r0 <br />2. Phone (Home): ( 56t - � (Work): ( 3 0 ) <br />3. Address (include former address if at present address for less than 6 months): <br />4603 SOU+\\ Cccen Pig i iiCeni\L-cjic;K u-)fi `tj33`7 <br />Physical <br />Gcc%e a3 (z60u1; <br />Mailing ` <br />4. Date of Birth: <br />5. Date and Time of Incident: <br />6. Location of Incident: <br />—(-%o F-Kk+ tai a Ca��a�► C� o�eQ <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised W2012 <br />