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A <br />03/04/2016 01:46:26 PM 201603040039 <br />$0.00 Page:1 of 8 <br />Claims Against County/rls/misc PROSECUTER <br />Kittitas County Auditor <br />IIIIIIII11111111111111111111111111IN111111111111111111111111111111111I11 1111 <br />Return to: <br />G <br />> � <br />NO...;� <br />CO SSIONM J 1. <br />�i' l w#&A fflw W-1 G <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />County Auditor <br />205 W 5th 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): <br />G rC3 A-• Lt oy 3k -y <br />Pet L • -4E'L3 a C A <br />2. Phone (Home): (Work): <br />3. Address (include former address if at present address for less than 6 months): <br />Mailing <br />4. Date of Birth: <br />5. Date and Time of Incident: <br />.36- II 12 ✓� <br />6. Location of Incident: <br />iCC l v -t. o a L kd <br />1 of 3 <br />1 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />