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PROSECUroll "'C.,""' -.;,,'? <br />COMMISSJONBRS::rlf:::;- <br />DEPARTMBNr ~ <br />lNSURANCB ~I <br />05/07/2019 03:91:11 PM 201905070021 <br />Si.CO Pase·1 or 4 ~ flT~~~o~t~l C~~m~h/111,l so KCPA <br />11mn mm~ 11111mi1rn11ri~ ~n.11111 rm m,m ,~ 111111111111111 <br />KITfITAS COUNTY CLAIM FOR DAMAGES <br />Return to : <br />County Auditor <br />205 W 5111 Ave, Suite 105 <br />Ellensburg, WA 98926 <br />509-962-7504 <br />Instructions: <br />Please read the entire fonn 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. <br />2. Phone (Home): (6Cl\-fqq . i)5.j]) (Work): ( t;t(J'.YW.., ) <br />3. Address (include fo .rmer address ifat present address for less than 6 months): <br />2e?D s.Jmrp H,1:~1E1rostvu ,r:9 ,1.uoc . 9%12L12 <br />Mailing <br />4. Date ofBirth: £.\,:).0\71.,p . <br />5. Date and Tt~ Incident: <br />g\d-0 d-0\13 <br />6. Location of Incident: <br />Erna i '\ reqi ,es\: \'"e,v{o,u boaxtl <br />1 of3 <br />Kittitas Co11Dty Cl.aim for Damages Form <br />Revised 9/2012