HomeMy WebLinkAbout07-25-2017 Claim for Damages - Eklund, AndreaU
PROSECUTOR
COWSSIONSRS '
07/25/2017 04:44:40 PM 201707250047
$0.00 Page:1 of 6
Claims Against County/rls/misc KCPROS
Kittitas County Auditor
1111111111111111111111111111111111 III 11111111111111111111111111111111 IN IN
KITTITAS COUNTY CLAIM FOR DAMAGES
Return to:
County Auditor
205 W 5th Ave, Suite 105
Ellensburg,. WA 98926.
509-962-7504
Instructions:
Please read the entire form before completion. Fill out each question as completely a's possible,
to the best of your ability. Do not hesitate to use the back side of this form if you need more than
the space provided. An incomplete response may delay the processing of your claim.
1. Name (Including spouse, if married):
2. Phone (Home): 2-r, 3 4t
3. Address (include former address if at present address for less than 6 months):
'53t �j n,. :��- �► `s�
Physical C
Mailing
4. Date of Birth: U..I& =
5.
6.
Date and Time of Incident:
I v i M ell s� °� 354.V
Location of Incident:
1 of 3
Kittitas County Claim for Damages Form
Revised 9/2012
Filed for Record 07/25/2017 04:44:40 PM - Kittitas County, WA Auditor - 201707250047 Page 2 of 6
7. Describe in detail the defect which caused the injury:
veAl,"tir���dn� Vi"iv,6tow
8. Describe in narrative form and in detail exactly how the incident occurred:
10
11.
12.
hey m fk 0` eCX- rSl QraveA HCl^^+j/\e-
e.fn n
0X-4 � vr-J- SL in. n AA.. •,r io
!� f?4, v ' � k4 -f ► t v V ' S i f/x � W y � O VNJ 1� C �t 1 '1• W CLS e!# P.t.�cl . te l c n ,f l3 -i Sp� '� CC -
'An, i
List th�r�am of a 1 persons involved an co tac mformatio , if Ycnown.
IM eA •-' ob 1 q .
Was claim investigated by a police officer? YN V
Sheriff State Patrol City Police
Description of claimant's vehicle: SOS Kl YL&- Make Year ION
Model: II vw tVt'L.C� License No. P HI -r-
- I
Describe what you did after the accident occurred:
-'1..P- vu, "Uw cLv,.k- c.�I lel
W(v VS "3 S D We, -VO S* 4't, +Uy vv� 100 1-) AA
13. Describe the conversations you had, if any, with County personnel during or after the
incident occurred:
Se -e, e S fi �v► 12-
2of3
Kittitas County Claim for Damages Form
Revised 9/2012
'Filed for Record 07/25/2017 04:44:40 PM - Kittitas County, WA Auditor - 201707250047 Page 3 of 6
14. Describe the damages or injuries which you sustained as a result of the .incident-
d�l nia, c a'1(� �l l/l� s i d�2 Y�`f, W1 oV\) 4-y'A 15. What is the amount of damages claimed? (Inclu estimates and bills, if available):
16. How did you identify the County as the party responsible for your damage?
17. List the names and addresses of all witnesses to the incident:
Y) a-
18. Are you covered by insurance? If yes, who is your insurance agent/carrier?
,-Faw w"
Dated this Day of JJIM , 20-.
Si ature of Cl ' n
Subscribed and sworn (affirmed) to before me this day of 520—.
Seal
Notary Public in and for the state of wasnmgton
Residing at
3 of 3
Kittitas County Claim for Damages Form
Revised 9/2012
Filed for Record 07/25/2017 04:44:40 PM - Kittitas County, WA Auditor - 201707250047 Page 4 of 6
'Filed for Record 07/25/2017 04:44:40 PM - Kittitas County, WA Auditor - 201707250047 Page 5 of 6
J.OHN90141cGLASSSUF2 1iGLYX{tL3titas County, WA Auditor - 201707250047 Page 6 of 6POPY 1
211 S. MAIN ST.
ELLENSBURG, WA 98926
PH:509-925-3777 FAX:509-925-5500
Federal Tax ID: 45-2549779
P/O#: Cust State Tax ID:
Taken By: Cust Fed Tax ID: Quote: Q003391
Installer: Ship Via: Date: 7/25/2017
Time: 04:33 PM
SalesRep: Adv. Code:
Bill To: MISC Sold To: MISC
ANDREA EKLUND
ELLENSBURG, WA 98926
253-347-9273
Vehicle Information
ANDREA EKLUND
ELLENSBURG, WA 98926
Sub Total: $579.12
Tax: $47.49
Total: $626.61
Make: Subaru
Model Style: Impreza 4 Door Hatchback
Year: 2014
Odometer:
VIN:
License:
Qty
Part Number
Description
List
Disc%
Sell
Total
1
FW03565GBNNPPG
Windshield -(Heated Wiper Park
$501.45
20
$401.16
$401.16
Area,W/Third Visor F
1
100F
100 flat (Flat Rate) (2.9 Hours)
$100.00
0
- $100.00
$100.00
1
HAH000004
Adhesive -(2.0, Urethane, Dam, Primer)
$30.00
.0
$30.00
$30.00
1
WFS F3564
Moulding
$47.96
0
$47.96
$47.96
Sub Total: $579.12
Tax: $47.49
Total: $626.61