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.. <br />Filed for Record 05/04/2016 11 :09 :49 AM -Kittitas County , WA Auditor -201605040003 Page 3 of 12 <br />14. Describe the damages or injuries which you sustained as a result of the incident: <br />~~ 11 rS E 'i> €; \"""'-'1 ~kc-t.-it2 jJ ~ <br />15. ount of damages claimed? (Include estimates and bills, if available): <br />. 'S22..~ <br />16. <br />17. ~st the names and addresses of all witnesses to the incide~ /" <br />S2tM F~n. I 253 ~( -tfJ; £0 S2 <br />18. Are you covered by insurance? _____ If yes, who is your insurance agent/carrier? SeRf {Y'-'i~ <br />Subscribed and sworn (affhmed) to before me this c:?38 day of v'Y\QJ\ch ,2olfL. <br />Seal <br />Notary PiiCiIlaIld for the State of Washington <br />Residing at ~Y\..~f1UMl..sb, lA.Ai <br />(J.,yn%Io, 5. Le<;N1 <br />30f3 <br />Kittitas County Claim for Damages FornI <br />Revised 912012