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Filed for Record 03/06/2017 11:19:05 AM - Kittitas County, WA Auditor - 201703060010 Page 3 of 8 <br />14. Describe the damages or injuries which you sustained as a result of the incident: <br />(1\,x 60'%AyeC Qi'A Gi Gic�je� SJ CQ�}S (fil7S Alli�C �%3e� <br />c ruA end , <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />NJ <br />16. How did you identify the County as the parry responsible for your damage? <br />�� a� r�i `sc�ss ��ng c���1� -tie co��.�� �et-s�a�► ed �,� <br />Ae scene r to w�A-h AV%Cer �errel0 <br />17. List the names and addresses of all witnesses to the incident: <br />hetc w ete <br />tooy, A <br />td Pss,-s e-Ac@4 <br />"khe.y <br />yr1X' es <br />18. Are you covered by insurance?�If yes, who is your insurance agent/carrier? <br />SA'Ae_ eY adviS-e'f me ftni f© (0 Q cls` �► <br />g ll t\-4 SkaAe VoCM -c"O \ce wevld kuc- to 5)Q tl�e- <br /># <br />Dated this 3 s A Day of 20 1� . <br />Signature of Claimant <br />` \ <br />d sworn (affirmed) to before me this day of NI(l`( '20 <br />40 OTA 'lee <br />�°,S'al51 <br />�_ ' <br />NA %, ,oGB��� s 2 otary Public in and for the State of Washington <br />'9j ,'�a,�o,pgA®; Residing atQ.Y1�oY1 <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />