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r <br />1l .. <br />14. Describe the <br />injuries w14ch you sustained a4 a result of <br />15. What is theamount if damages claimed? (Include estimates and bills, if available): <br />15. How did ou 'den ' e Count%y as the party esponsible f r your c <br />r <br />E L <br />-Crdl lW �S, 45 ds Gk�,f/.S i <br />17. List the names and addresses of all witnesses to the incident: <br />18. Are you covered by insurance?f yes, who is your insurance agent/carrier? <br />Dated this —0—Day of"7�/ , 20_T. <br />n _ ri <br />3 <br />of t.iaimani - <br />Subscribed and sworn (affirmed) to before me this �day of _,,, �. 20_�V <br />Seal <br />RV—A L p �r�� _ c-� -O <br />No Public in and for the State of Washington <br />SION <br />c� "OTA# .9�,� Residing at \\o l 1 QnA-n <br />V9�'4F9_o 3 of 3 - <br />/I 1 I''WAS\Ax Kittitas County Claim for Damages Farm <br />Revised 9/1012 <br />