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/ <br />05/04/2016 11:09:49 AM 201605040003 <br />$0.00 . Page:1 o f 12 <br />Claims Rgainst County /rls/mlsc KCPROS <br />Kittitas County Ruditor 11111 m IIIII11I II I~' 11I1 mn mmll W lll~ n 1111 mti mm <br />PItISiUtfOR((Z .!b 2-;3 <br />~10~. <br />DEPAJn'MENT .. P_IP_~ <br />INSURANCB -..;;..H ___ _ <br />KITmAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5th Ave, Suite 105 <br />Ellensburg, W A 98926 "" 2-~~\ <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 riot 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 />1. Name (Including spouse, ifmarried): <br />2. <br />3. <br />4. <br />5. <br />6. <br />Phone (Home): ...... ( ____ --.r.)(Work): (t;2.'~ 1~ -(,]2 ., <br />Date of Birth: -------------------- <br />Date and Tilt of Incident: t\ \"h."'t~ 1 24lb ~··cru <br />10f3 <br />Kittitas County Claim for Damages Form <br />Revised 9120 J 2