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r^ROSECUTUR. 6—z— <br />COMivOSSIONERS �— <br />DEPARTMENT, <br />INSURANCE J� _ <br />08/16/2017 03:23:28 PM 201708160073 <br />$0.0 Page:1 of 5 <br />Claims Against County/rls/mise TNESA SLOAN <br />Kittitas County Auditor <br />11111111111111III1111111111!1111111111111111111IIIA1111111I1IIIA111111111X111 <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5's Ave, Suite 105 <br />Ellensburg, WA 98926 <br />509-962-7504 <br />Lzstractioas- <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 />2. Phone (H t(:)(Work): ( SOLA,\ —;. ) <br />3. Address (include former address if at present address for less than 6 months): <br />Z 3! O fAJ , E 11 M o �-o to 9-, l fl e �S <br />0 Sox � f 1[f&3S bcdr c, .t nf6 q0q`a <br />Mailing p <br />4. Date of Birth: ) a 3 )- 6 S <br />5. Date and Timq of Incident: <br />Og�l11'7,cx�Arr�x 9a`�Svn <br />�. Locatton:.ofi inc:;aarri: n r– <br />CL�.� � iCo,_uc�W2r2-5 1—ir2.ic�. <br />closes 0 I BcawFY0 <br />X=as County Claim fm.Dwagn Fm <br />Rmsed`ROM <br />