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Filed for Record 05/07/2019 03:51: 11 PM -Kittitas County, WA Auditor -201905070021 Page 3 of 4 <br />14. Describe the damages or injurie~ which you sustain~d as a result of the incid~nt: . /·. rue :TD ::ttv.oeb\, \D· ::ID# '<:e\/\:0 &) X'>Q1fo roer:firt:,) ·· <br />I ,ms \Ci± a...\\() 1:ro:\ "TI) 'clWYm DtU) £~,O'?e3. &he.. i+-~ <br />~ ~ Gu:\· o ~ -tiYY\12. Toi-s C..Y-ectkd C<!... \cSS ~ r-ci~vs~t...¼ oC <br />15. What is .the amount of damages claimed? (Include estimates and bills, if available): ·:\t ,;t 1~74,.;i..1. <br />16. How did you identify the County as the parfy.rcspensible for your damage? <br />?'ccJae. CDO\Jt'f50:boos ax:tl e..roo,.,t,o~ tPith <br />Q;)'<D-\Jab~:s a ad. De.la'cie molje.-rs. <br />17. List the names and addresses of all witnesses to the incident: <br />SAXO;,,Don f:{":PS cor-d Dm\Q\f' mc~~r:s --K\-\\i-ns <br />Cru~ b:n9\a~es. . .. <br />~-. Cm.t0{ixd -L\;>gb ¼°fu:W,S\.-'t~~\\~-~ <br />18. Are you covered by insurance? NI A. If yes, who is your insurance agent/carrier? <br />/ <br />Dated this 3 rel Day of~M~o..~~----~· zoJB <br />Signa~ <br />Subscribed and sworn (affirmed) to before me this_Lday of__...M....,:J~----'' 20..l.1. <br />G:::d>, ~ <br />Notary Public in and for the State of Washington <br />Residing at /lle¢rb;;.,..~A--U '7--92LLP <br />/Je <: I .L. \.L.J!;;> a:, sir/'): <br />3 of3 <br />Klltiw County Claim for Damages Fonn <br />Revised 9/2012