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Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 3 of 16 <br />14. Describe the damages or injuries which you ustain d as a result of the inc'dent: <br />Pnr�n,l ie.r%r n� -re na( Ii n' u,< ,rtP_g � ern-)ck1tvmek <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />As 0-F 1Olsl1-1 s-VvAtrrA01A xt03.:5 <br />��. 50 (Am I91.IAOC-L) a►��.go I E� vl si i Oloc <br />16. How did you identify the County as the party responsibly for your damage? <br />17. List the names and addresses of all witnesses to the incident: <br />e.� stal in�5 <br />18. Are you covered by insurance? 'I'L s If yes, who is your insurance agent/carrier? <br />5e-ir �P�V1r1 0C4�,p <br />Dated this _Day of �J , 20. <br />aa no <br />L1.3q:oo) <br />6 <br />Subscribed and sworn (affirmed) to before me this day ofLtt�i� 20 <br />Seal \\ �\ •.......• �� �, <br />\� �;•�55�0N"Ai'•� Notary Public in and f r the State of W shmgton <br />OSAR Y9N�'; cResiding at GC S i'X7u <br />• <br />pig\ -\G O = OU"a�r UJ <br />••.;UNE 05 ;�• �Ci\�` <br />OF W NS'��\ 3 of 3 <br />1 I I I1 ` Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />