Laserfiche WebLink
PROSECUTO <br />COpMS5I0NERS� <br />DEPAEZ'r[1+[O11y' <br />INSURANCE I - <br />05/07/2019 03:51:11 PM 201905070021 <br />$0.00 Paee:t of 4 <br />Claims Against Countytrlslmiso KCPA <br />llllllllllf III IIl Count A <br />lIlllIllhllll li[II Ijlll 1111111 III 11111 Ilii) Illi ilfl <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5's 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 />2. <br />4. <br />5. <br />6. <br />Phone (Home): ( 501 ST1 ,1541) (Work): ( L�'YIP-� ) <br />Address (include former address if at present address for less than 6 months): <br />Mailing <br />Date of Birth: <br />Date and Time of Incident: <br />Location of Incident: <br />—ma i l <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 912012 <br />