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Filed for Record 08/12/2019 02:59:52 PM - Kittitas County, WA Auditor - 201908120064 Page 3 of 4 <br />Sn urr �`f t► �n h <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />q 9. q + 4onc 53 RO-97 <br />16. How did you ide ify the, unty as t e p res onsible for moue dam e? <br />I <br />17. List the names and addresses of all witnesses to the incident: <br />V -U MCUSu" 12311 157 ft tilk SMOR,EL,WE,WA Qgi5S <br />18. Are you covered by insurance? If yes, who is your insurance agent/carrier? <br />jou <br />r -O lop i for <br />Dated this Day of T —,204. <br />Signature of Claimant <br />Subscribed and sworn (affirmed) to before me this day of 20. <br />- SealFNICOLE <br />y Public <br />Washington <br />OSHINSKY <br />ON# 205250 <br />SION EXPIRES <br />r 24, 2022 <br />Notary <br />Residing at <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 912012 <br />