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r <br />'Ti Z/ <br />"PA"TNIENT Y <br />01/06/2011 03:45:29 PM 201101060022 <br />$0.00 Page 1 of 5 <br />Claims Against Countylrlslmiso K CO <br />Kittitas County Auditor <br />1IIIIIII111111 IIIIIIIII IIIIII IN IIII IN 111111111111111111111111111111111 <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): Gen g- iZ ar�Cg a,�) 1 C . G 20 S6e:- <br />2. Date of Birth: 13 G <br />3. Phone #: (Home): 62s 6 7 4 -1 <br />4. Address (include former address if at present address for less than 6 months): <br />r, ;I-,-% -rS7" _ A. - _ 0 1 r I _ Ci.. %.N I !. Pta % --� <br />5. Date of Incident: \ V� <br />6. Location of Incident: 4 rO �r-c1 C.i �.,, C� V� „�c �Le- <br />Page 1 of 3 <br />