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E1 <br />I� <br />01/06/2011 03:45:29 PM 201101060019 <br />$C 00 Page 1 of 4 <br />Claims Against County/rls/mist K CO <br />Kittitas County Auditor <br />11111111111111 III 1111111111111111 IN 111111111111111 III VIII VIII VIII Ilii 1111 <br />KJTTITAS 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 backside 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):(Ci v) Y1 <br />2. Date of Birth: <br />3. Phone #: (Home): ��� (Work): (__) *4M 5i <br />4. Address <br />5. Date of Incident: -� <br />/02 <br />6. Location of Incident: <br />Page 1 of 3 <br />for less than 6 months): <br />