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U <br />PROSECUTOR <br />COWSSIONSRS ' <br />07/25/2017 04:44:40 PM 201707250047 <br />$0.00 Page:1 of 6 <br />Claims Against County/rls/misc KCPROS <br />Kittitas County Auditor <br />1111111111111111111111111111111111 III 11111111111111111111111111111111 IN IN <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <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 a's 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 />2. Phone (Home): 2-r, 3 4t <br />3. Address (include former address if at present address for less than 6 months): <br />'53t �j n,. :��- �► `s� <br />Physical C <br />Mailing <br />4. Date of Birth: U..I& = <br />5. <br />6. <br />Date and Time of Incident: <br />I v i M ell s� °� 354.V <br />Location of Incident: <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />