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Pre§ecut©r.s Office <br />FED 14 vZ0|7 <br />Civil Divisionr.RasEEci"R <br />`{#y`€ttt£`C;EORERSJi± <br />I,,fA9m,+5anue..~ <br />_u!!_uqucB_- <br />©2/@8/201711:56:49 flM <br />00 <br />ims against Cc)unty/r`ls/misc <br />ti`as County audit <br />11111111111"111111111111111111111!1 <br />2© 17@2©88© 11 <br />Page:1 of 10 <br />K C0 PROSEC <br />KITTITAS COUNTY CLAM FOR DAMAGES <br />Return to : <br />=o°5u#y5A|dv!::;uitel05 <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): <br />i c`n H```\\€' ;09?¥5`=r,.,:c 7L).`m+ a+ t\Lt`\\f-v <br />Phone urome):i,-a ,;, - i; j' 5', >~q-a iOvork): ( ) <br />Address (include fomer address if at present address for less than 6 months): <br />I)hysical <br />m#70 j'.-+hw€n~ f`7uo\cl, 5i|ah WA JU`9q-2~ <br />DateofBirth: O®/o` I lJlz, <br />Date and Time of hcident: <br />C\?erT,`+ 11 O\.Tn. oi` -TLnun:) `13, 2cn <br />=2¥°2n7°f]ne#ti±b___\__)G#o`.i\£___G||?"bv`ri±,W.A <br />1of3 <br />Kittitas County claim for Dzimages Form <br />Revised 9/2 012