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'Filed for Record 07/25/2017 04:44:40 PM - Kittitas County, WA Auditor - 201707250047 Page 3 of 6 <br />14. Describe the damages or injuries which you sustained as a result of the .incident- <br />d�l nia, c a'1(� �l l/l� s i d�2 Y�`f, W1 oV\) 4-y'A 15. What is the amount of damages claimed? (Inclu 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 addresses of all witnesses to the incident: <br />Y) a- <br />18. Are you covered by insurance? If yes, who is your insurance agent/carrier? <br />,-Faw w" <br />Dated this Day of JJIM , 20-. <br />Si ature of Cl ' n <br />Subscribed and sworn (affirmed) to before me this day of 520—. <br />Seal <br />Notary Public in and for the state of wasnmgton <br />Residing at <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />