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- ' Filed for Record 02/16/2016 10:12:22 AM - Kittitas County, WA Auditor - 201602160002 Page 3 of 4 <br />14. Describe Jhe damages or injuries which you sustained as,a result o�the <br />15. What is the amount of damages claimed? (Include estimates and bilis, if available): <br />rx <br />rr <br />11 <br />16. H1 w dy you iderl ify the County as the party esp❑ sible fa your damage? <br />.... - --•f — - •- ----. __.- <br />17. List the names and addresses of all witnesses to the incident: <br />W <br />15,4za &A/ <br />Are you covered by insurance?zLrIf yes, who is your insurance agent/carrier? <br />Subscribed and sworn (affirmed) to before me this Q day of , 20) tv. <br />Seal `••���►��tRo �W +r���rt•¢ • • <br />.•` P .•�*•.,'�� Notary Public in and for the State of Washington <br />Residing at L <br />& <br />PUBM a <br />OF <br />M ,��.��•.•' 3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 912012 <br />