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01/25/2016 04:51:36 PM 201601250078 <br />Claims Against County/rls/miso PPROSECUTOR <br />1i1i1i111i1ii1iii ililiii1i1i1111111111111111111111111111111111111111111`n111a1 <br />PROSECUM R <br />COIYMSSIONERS,) <br />DEPART&1ENT M� <br />INSURANCE <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 -W 5s' 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 />�c S�V`rJ 7 <br />2. Phone (Home): ( 1(Work): 1115 — (} > <br />3. Address (include former address if r ent dress.for less than 6 mon <br />Mailing <br />4. Date of Birth: <br />5. Date and Time of Incident: <br />6. Location of Incident: . <br />7k /W ivl0aH ;iVN!4A, �t <br />1 of 3 <br />W,-, C/es—a� <br />Kmitas County Claim for Damages Form <br />Revised 9/2012 <br />