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Filed for Record 03/04/2016 01:46:26 PM - Kittitas County, WA Auditor - 201603040039 Page 4 of 8 <br />14. Describe the damages or injuries which you sustained as a result of the incident: <br />k c 4 ► res J -,n G,1, 7 / r-Ati1,4o,v s . N,I b f'54.e <br />1 61 <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br /># A 19 (. /( 4,Titvr� <br />�S <br />16. How did you identify the County, as the party responsible for your damage? <br />7f4- wa S Gauer d wv4(2-vue1< ° S" -u i ✓I <br />17. List the names and addresses of all witnesses to the incident: <br />r <br />MI <br />Are you covered by insurance?T,7 If yes, who is your insurance agent/carrier? <br />S 6Y - <br />Dated this _ <br />of Clai <br />h ( (�4&V61rz .TYL5, - S6I - <br />9-0110 v wa i <br />_Day of A,1 u- v -C 1-� , 20_L_6. <br />09- -5oy3 <br />y <br />Subscribed and sworn (affirmed) to before me this day of J, 20_1� <br />.�ow111110o't,,� - <br />��` 1�A NAT ��✓i/ <br />Seal .•ARNP.......••/ A- <br />OTA Notary Notary Public in apA for thp State of Washington <br />• = Residing at Ez <br />PUBUVO ,�• Z` <br />•/'9 • �9OAFN ••• <br />Op <br />/// �� ••4•••N••��\ <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />