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Filed for Record 01/25/2016 04:51:36 PM - Kittitas County, WA Auditor - 201601250078 Page 3 of 4 <br />14. <br />or iniuries which you0hstained as a result of the incident: <br />15. Whakis` amount of aumages claimed? (Include estimates and bills, if available): <br />16. Ho -w dad you i <br />Kdentify the Countythe ariy re o ble for -pr dama <br />�—a. <br />17. List the names and addresses of all witnesses to the incident: <br />18. Are you covered by <br />who is your insurance agent/carrier? <br />Subscribed and sworn (affirmed) to before me this oda day of ��11 20�. <br />Seal <br />Notary blitin an�d�£or the State of Washin <br />n <br />Residing at�1O�(Sh I <br />``t�g1111111I/'/ <br />ass <br />3 of 3 <br />o NOTARY �N. a Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />Nom? PUBLIC <br />2® <br />9��c`"•.o.oe, erg �j'`O``. <br />