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'Filed for Record 04/12/2018 02:20:26 PM - Kittitas County, WA Auditor - 201804120025 Page 3 of 7 <br />14. Describehe damages or injuries which you sustained as a result of the incident: <br />�L%L Oryer`S SccJe. 0�- Jrt' k nOW kqS Sf_dtr-c` I <br />_P014- c4ys- grow Int*(" '1 �. <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />� 1, pip. do - see a44aCk46 rTa„r- U4 -f . <br />16. How did you identify the County as the partyfesponsible for your da age? <br />r�Sel r. ck ..e� SQwk 4F IIn ev , e�� 4-wF +ke 00"P <br />+u -00t w i f -V., +kx COO+ti ► 090 Ot- 1,H . <br />17. List the names and addresses of all witnesses to the incident: <br />e5ay.. £ l I tnater <br />%o C--,OQ*"riC1CJQ. Or. <br />Elk"s-b'yJ , t -i A 9%qXo q- 927ct- 9"19-7 <br />18. Are you covered by insurance? VeS If yes, who is your insurance agent/carrier? <br />s4c,4e Sco if go Il i ,,'S <br />Dated this l)L Day o A r� f , 20 <br />1,x -A^ � <br />of Claimant <br />Subscribed and sworn (affirmed) to before me this' day of J, 20 Ir <br />\\��t\llllll-11//j�/s <br />Seal .�`��eL`y •Sso �'!p''' <br />.O 9 <br />• �' %AOTAgy N — <br />PUBLIC <br />�9�FA B 3� 16 -A- <br />EH <br />1WASY\ <br />Notary Public in p#dlfor the State 4 Washington <br />Residing at en' <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />