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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 <br />iv 6` Cit/ <br />as a result of the.incident: <br />15. What is the amount of damages claimed? (IncluZkestimates and bills, if available): <br />16. <br />17 <br />did you identify the County as the party responsible for your damage? <br />List the names and addresses of all witnesses to the incident: <br />18. Are you covered by insurance?'I e S_If yes, who is your insurance agent/carrier? <br />S' • CZW Y1/\ <br />Dated this <br />of J J� 20 . <br />l� <br />Subscribed and sworn (affirmed) to before me this Iday of _ <br />Seal <br />r� <br />Notary Public in and for the State of Washington <br />Residing at <br />3 of 3 <br />Kittum County Claim for Damagu Form <br />Revised 9/3012 <br />