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Filed for Record 08/16/2017 03:23:28 PM - Kittitas County, WA Auditor - 201708160073 Page 3 of 5 <br />14. Describe the damages or injuries which you sustained as a result of thg incident: <br />a.S% 44 &2 zv-4 Fn <br />15. What is the amount of damages claimed? (Include 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 alt witnesses to the incident: <br />P >. ri fX,'�-T '4��- is °•F q °) Ell <br />V -1�-ovs()ii a) L qE-7 <br />18. Are you covered insurance?y insurn�,ce? <br />pM <br />-A <br />Dated this <br />f~� <br />Eyes, who is your insurance agenticarrier? <br />Subscribed and swom (affirmed) to <br />3 of 3 <br />Kittitas Cmmty Claim for Damages Form <br />Bisised. All <br />