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�'ITYIENT� -- <br />i a ICE 4, _ <br />01/06/2011 03:45:29 PM 201101060018 <br />$0.00 Page 1 of 4 <br />Claims Against Ceuntylrlslmiso K Co <br />Kittitas County Auditor <br />111111111111111111111111111111111 11ii 11111111111!! II11111111 1III <br />KITTITAS 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):=-Ei� ►� Q� n:�� .____ <br />2. Date of Birth: Z 7—:5 Ln (0 0 <br />3. Phone#: (Home):Qf Work): <br />4. Address (include former address if at present address for less than 6 months): <br />'57'0 e 1/A u.,;5 / C -k eLy" OA- `-[ `!)cj <br />Date of Incident:- AN �i 7, ZL6'� <br />6. Location of Incident: A --f- Arl-;OVE 49PaAZS5 <br />Page l of 3 <br />