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Filed for Record 12/26/2018 1 2:11:26 PM - Kittitas County, WA Auditor - 201812260036 Page 3 of 3 <br />14. Describe the damages or injuries which you sustained as a result of the incident: <br />�J�.S r�GtnS/J y! -3•�r r G!r/efr. oL ��Gr�� <br />Re - <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />A <br />�57- <br />16. How did you identify the County as the party responsible for,.your damage? <br />17. List the names and addresses of all witnesses to the incident: <br />18. Are you covered by insurance? PO If yes, who is your insurance agent/carrier? <br />Dated this Z6 Day of ��C�1M�` , 20J&. <br />Signature of Claimant <br />Subscribed and sworn (affirmed) to before me <br />2016. <br />Seal <br />Not blic in and r the �Sj of shi gton <br />5510 N �' '�Residing at + �� <br />1�0� <br />�OTAIgy <br />P <br />UBL.IC r ' 3 of 3 <br />k: Kittitas County Claim for Damages Form <br />4 :• ,� Q ��� Revised 9/2012 <br />26. <br />4,410� WAS; ;�► ``�� <br />M uW <br />