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► Filed for Record 10/13/2017 02:21:20 PM - Kittitas County, WA Auditor - 201710130040 Page 3 of 8 <br />o <br />14. Describe the damages or injuries which you sustained as a result of the incident: <br />elO I'/TA,d �47- <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />10, 6N) 4 <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 />18. Are you covered by insurance? y If yes, who is your insurance agent/carrier? <br />/TG <br />Dated this G,' Day of C -1 ca '20/- <br />I <br />r / I -All- <br />of Claimant <br />Subscribed and sworn (affirmed) to before me this day of , 20_. <br />Seal <br />Notary Public in and for the State of Washington <br />Residing at <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />