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f �;t)hln�iG` <br />j; Z-JRANCZ <br />01/06/2011 03:45:29 PM 201101060026 <br />$0,00 Page 1 of 6 <br />Claims Against County/rls/misc K CO <br />Kittitas County Auditor <br />1111111111111111111111111111111111111111 IIII 11111111111111111111111111111111 IN IIII <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. ame (Including spouse, if married): �— • T/G�'� <br />2. Date of Birth: <br />3. Phone #: (Home):( ) (Work):. RjL — 0'7JQY- <br />4, v?i3�ie3 (incl�f�����ss if at present address for less than 6 months): <br />5. Date <br />6. Location of Inci <br />Page 1 of 3 <br />