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02/16/2016 10:12:22 AM 201602160002 <br />$0.00 Pageit of 4 <br />Claims Against Countylrlslmisc KITTITAS COUNTY PROS <br />Kittitas County fiuditor <br />11111111111111111111III II11111111 l�11 !III! 111lI1111i !Illi fill 1I1! <br />PROsECUMK- . „ <br />CON&USSIONM - <br />Dr.PARTMEN`I' G <br />INSURANCE <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return. to: <br />County Auditor <br />205 W 5`h Ave, Suite .I05 <br />Ellensburg, -WA 98916 <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. Marne eluding spouse, if m ed : <br />i74vL-S Y,�.,s Y -W' UX i <br />2. Phone (Home):01 } (Work): { } <br />3. Address (include former address if at present address for less than 6 months): <br />Ph Ica] ' <br />Mailing <br />-4. Date of Birth: <br />5. Date and Time ofIncident: <br />f PnA <br />6. Lo tion of Incident: <br />4 <br />1 of 3 <br />Kittitm County Claim for Damages Form <br />Revised 912012 <br />