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PARTIVI—NI 01/06/2011 03:45:29 PM 20d101060023 <br />$0.00 <br />ge 1 of 4 <br />Claims Against Countylrlslmisc K CO <br />Kittitas County Auditor <br />11111111111111111111111111111111 IN 11111111111111111111111111111111 IN <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: County Auditor <br />205 W 5th, Suite 105 <br />Ellensburg, WA 98925 <br />• 43f M "�.T-• <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 thr, 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): N L9TY►, _tQ±L <br />2. Date of Birth <br />3. Phone #: (Home):(N 6 7�-SiskVork): <br />4. Addr(includefaring address if at resent address fqr less than 6 months): <br />5. Date of Incident 1 r.; 2 on <br />6. Location of Incident: \,t <br />Page 1 of 3 <br />