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MUR MM <br />COMSSIONM <br />10/13/2017 02:21:20 PM 201710130040 <br />$0.00 Pa9e:1 of 8 <br />Claims Against County/rls/misc KC PROS <br />Kittitas County Auditor <br />1111111!111 II III I I III III 11111111 III 111111111111 III IIII I II III! <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor. <br />205 W 5h 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 />2. Phone (Home): (M4 �D;'_IeVf ) (Work): ( ) <br />3. Address (include former address if at present address for less than 6 months <br />Mailing <br />4. Date of Birth: !9 ��d <br />T <br />5. Date and Time of Incident: <br />6. Location of Incident: <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />