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_, <br />Filed for Record 01/06/2011 03A5:29 PM - Kittitas County, WA Auditor - 201101060026 Page 3 of 6 <br />16. List the names and addresses of all witnesses to the incident: <br />4J07" l!/.���7 �? ST- " <br />17. Are you covered by insurance?4 'AMMO 8% --_ If yes, who is your insurance <br />agent/carrier? �tGT=' - -- - -- - - <br />Dated this 4� Yk- Day of , 20 <br />Sigfature of Claimant d <br />* * <br />*-Notary <br />Verifiedgna a of Claimant <br />Subscribed and sworn (affirmed) to before me this A_e Day o W !>r ? 20// <br />Seal z <br />M. <br />Page 3 of 3 <br />Notary Public in and for the State of Washington <br />Residing at �� -� <br />