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Prosecutor �v <br />Commissioners iL <br />Department m� <br />Insurance .f P ` <br />08/12/2019 02:59:52 PM 201908120064 <br />$0.00 Paget ai Q <br />Claims Against Countylrlslmisc KC PROS <br />Kittitas County Auditor <br />11111111111111 IIII 111111111 11111 IIII 11113111111111111111141111111111111111 IIII <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />_ County.Auditor - <br />205 W 51 Ave, Suite 105 <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): DAVID M. P A u LSLL- <br />2. <br />3. <br />4. <br />5. <br />6. <br />Phone (Home): 5 - (Work):20t -qa <br />Address (include former address if at present addrels for less than 6 months): <br />Mailing <br />Date of Birth: 6 <br />Date and Time of Incident: _ _ M 6 0 Ay JULY 2120171 m. l r 4S D rn <br />Location of Inci <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />