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.........o....,.-_ - - - --- <br />MMM <br />�qp �' 11/01/2018 01:12:35 PM 201811010016 <br />$0.00 Page:1 of 5 <br />Claims Against County/rlslmisc KC PROS <br />Kittitas County Auditor <br />.4., ! ll 111111! ll [ll ![1111111 II II l Illll I 11 111111 INIII <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5"' Ave, Suite 105 <br />Ellensburg, WA 98926 <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 />1. Name (Including spouse, if married): <br />Cesar Va uera - employee of Interstate Batteries of Apple Valle <br />Bryan Calamia - Vice President of Interstate Batteries of Apple Valley <br />cell <br />2. Phone (Ig): ( 509-731-7537 )_ (Work): 509-457-3640 <br />3. Address (include former address if at present address for less than 6 months): <br />2001 Ahtanum Rd Yakima, WA 98903 <br />Physical (Business addresses) <br />PO Box 8311 Yakima WA 98908 <br />Mailing <br />4. Date of Birth: 1/3/79 Cesar <br />5. Date and Time of Incident: <br />10/25/18, 3:00 PM to 4:00 PM <br />6. Location of Incident: <br />925 S lndustri I Way <br />Ellensbure. WA 98926 <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 912012 <br />