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03/08/2018 03:12:32 PM 201803080044 <br />-i1 SU 0Q Paged of 7 <br />Clams Against Countylrlsi�wc KC?ROS <br />1 Ki tltl 'alslCo MAUtll tor� <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5'I' Ave, Suite 105 <br />Ellensburg, WA 96926 <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 />Name (Including spouse, if married): <br />Kittitas County PUD NO, 1 <br />2. Phone (Home): { ) (Work): ( 509-933-7200 <br />3. Address (include former address if at present address for less than 6 months): <br />1400 VANTAGE HWY, ELLENSBURG WA 98926 <br />Ph%slcal <br />SAME AS ABOVE <br />Ma'b"-, <br />4. Date of Birth: <br />5. Date and Time of Incident: <br />DECEMBER 18. 2017 AT OR AROUND 16.00 <br />6. Location of Incident: <br />LOWER GREEN CANYON ROAD, 1.6 MILES SOUTH OF SMITHSON ROAD <br />1 of 3 <br />Hnrnis Cm:n:e UU,I , ioi' Dan',ag,, Form <br />R era ..I 112012 <br />