Laserfiche WebLink
01/25/2016 04:59:08 PM 201601250079 <br />$0.00 Page:i of 4 <br />Claims Against County/rlslmiso PROSECUTOR <br />Kittilas County Auditor <br />1111111111111111111111111111111111111111111111111111 <br />PROSEI<'U7R (S <br />COMMISSIONERS,„ <br />DEPARTMENT Z <br />INSURANCE <br />KTfTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />-205 W 5t' Ave, Suite .105- <br />Ellensburg, WA 98926 <br />509-962-7504 <br />Instructions: <br />Please read the entire form before completion. Fill out each question as completely as possible, <br />to the best of your ability. Do not hesitate to use the back side of this form if you need more than <br />the space provided. An incomplete response may delay the processing of your claim <br />1. Name (Including spouse, if married): <br />2. Phone (Home):( 50'163 I� 17 )(work): (" I W-ZW) <br />3. Address (include former address if at present address for less than 6 months): <br />4. <br />5. <br />6. <br />Physical 9N J_,1 ;—L Mil' LA .'F/I1Y/VlS64 <br />sung J_. <br />Date of Birth: <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 92012 <br />