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Prosecutor fS� - <br />Commissioners w - <br />Department, M <br />insurance JP - - <br />0g8/12/2019 02:59:52 PM 201908120064 <br />EMIL Against county/rislmiso PKG PROSt 6 <br />Kills tas Count Auditor <br />iI11111111111INIIIIIIINII�IIIIIII111NIHIliIt�IIIIIIIIIfIIIIIIIIINIIIIIIIIIiItI <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County.Auditor <br />205 W 5' Ave, Suite I05 <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 />1. Name (Including spouse, if married): DAY 16 TA [ S E—L <br />2. Phone (Iiome):(204)5W?^9293 )(Work): 20i4mm, <br />Address (include former address if <br />Mating <br />4. Date of Birth: 3! G/ f 9 67 <br />—7 <br />for less than 6 months): <br />5. Date and Time of Incident: M614ZAY a L y 242017 at f <br />6. Location of <br />I of <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />