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PROSECiTTOit 1� <br />C[�LIWI SSIONERS_ <br />01/06/2011 03:45:29 PM 201101060020 <br />$0 00 Page i of 4 <br />Claims Against Countylrlslmisc K CO <br />Kittitas County Auditor <br />1111111 #VIII III IIII 1111111111111 IIII IIII VIII 1111111 III I III VIII VIII IIII III <br />KITI`ITAS COUNTY CLAIM FOR DAMAGES <br />Return to: County Auditor <br />205 W 5th, Suite 105 <br />Ellensburg, WA 98926 <br />Instructions: <br />Please read the entire form before completion. Fill out each question as completely as possible, to <br />the best of your ability. Do not hesitate to use the back side of this form if you need more than the <br />space provided. An incomplete response may delay the processing of your claim. � /� <br />1. �Name� (Including spouse, if married): M r ke-J 1 V1 Co o ns a vt ct ,� V l fs <br />�_/v�_ U10nS <br />2. Date of Birth: _ _kem vi % Z ) 4 / 6,4 M e a q : 9/U/62- <br />3. <br />/Uf6- <br />3. Phone#: (Home): ' S7vq&Work): ( �6S-b) 42E- - LSaD <br />4` Address (include former address if at present address for less than 6 months): <br />(Qua -m Mtecl "Pld, Ole- WA 90YZ75 R.Lf) <br />5. Date of Incident: _ . _ �iy�tAa rr (4 2 W C <br />6. Location of Incident:_ 501 ( (DVu-,I Val (4!V KGl _ C E Lu tj.. W ,4 <br />Page 1 of 3 <br />