Laserfiche WebLink
Filed for Record 11/15/2017 03:47:58 PM - Kittitas County, WA Auditor -201711150066 Page 3 of 8 <br />14. Describe the damages or injuries which you sustained as a result of the <br />9 incident: <br />Alava_ -7t. ✓yw �o%1' 1l✓1,n Ah, i, o -717) -/%-a <br />-a_ Pa/' i J2C --4 min /v / WA /- /J-% <br />nl'r(im-ir <)de r -ea r Gr >7a n e A4 y, -% a a <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />x.6.0 <br />16. How did you identify the County as the parry responsible for your damage? <br />% A&-5 n a b;-4'(' d /J -y <br />(2 <br />17. List the names and addresses of all witnesses to the incident: <br />18. Are you covered by insurance? ,, If yes, who is your insurance agent/carrier? <br />3 0 0 IZAA <br />Dated this I H +:� Day of Nuv-e-� Fj�e-r' -,201-7. <br />Signature of Claimant <br />Subscribed and sworn,(, Mpd) to before me this day of /V ftm h.l,r' , 201-7. <br />GOA D'q <br />Seal O ` Q <br />, <br />d <br />Notary Public in and for the State of Washington <br />JSt ICS ,®° Residing at G <br />I. <br />\'� c° ry201 00 �C)VA S <br />�j�/�h°ae aoeo°°° � ♦1\` L,]LI.JL�Q.� I / K - /J�\moi <br />111111100 <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />