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Filed for Record 01 /25/2016 04:59:08 PM - Kittitas County, WA Auditor - 201601250079 Page 3 of 4 <br />14. Describe the damages or injuries which you sustained as a result of the incident: <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />- 5 <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? If yes, who is your insurance agenticarrier? <br />Dated this A --U Day of 20U. <br />Subscribed and sworn (affirmed) to before me this day of <br />Seal <br />-votaryYumic in anu xor the Zitate or Wasnington <br />Residing at <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />