Laserfiche WebLink
pROSEE7U10�-�'—'l 07/25/2017 04:44:40 PM 201707250047 <br />CP <br />Claims Against County/rls/misc KCoI 6 <br />PROS <br />�AM&1I$$IOIQEI� Kittitas County Auditor <br />DIN J IIIIIIIItilllll�llllllllllllllllllllllllllllllllllllllllllNII�III!I�IIIIII <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 />1. Name (Including spouse, if married): <br />U <br />2. Phone (Home): ( (b orl k): (7S 3 -W4 .01 Z 3 <br />3. Address (include former address if at present address for less than 6 months): <br />L o a_ F-111Wl,%6Vj,w WA - <br />Physical <br />4. Date of Birth: U-* i "} <br />5. Date and Time of Incident: <br />111A 21 sfi 'I:'35�wt <br />0 <br />Location of Incident: <br />I of 3 <br />Kittites County Claim for Damages Form <br />Revised 92012 <br />