Laserfiche WebLink
Filed for Record 08!12/2019 02:59:52 PM - Kittitas County, WA Auditor - 201908120064 Page 3 of 4 <br />15. What is the amount of damages claimed? (Include estimates and bills, if available): <br />*' 89.9° +4a * 53R.97 <br />16. <br />17 <br />List the names and addresses of all witnesses to the incident: <br />Usa Me-Usu tJ 19311 IV! PL ME SHpRELWF,' ISA QgtSS <br />18. Are yyou covered by insurance? If yes, who is your insurance agenticarrier? <br />6M ADIDQIP1 <br />Dated this Day ofQUCTl1ST —,204. <br />Signature of Claimant <br />Subscribed and sworn (affirmed) to before me this --g day of/J¢_ 20/,0. <br />Seal Notary Public <br />State of Wasbi40SHI gtoa Nota c in and r the State of Washington <br />NICOLE MOSHIN 4) Notary <br />COMMISSION#205250 Residing at ^ <br />My COMMISSION EXPIRES <br />November 24, 2022 <br />3 of 3 <br />Kiltlmas County Claim for Damages Form <br />Revised 92012 <br />