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ERS 01/06/2011 03:45:29 PM 201101060024 <br />rt HERS $0.00 Page 1 of 4 <br />Claims Against Cri5im15C K CO <br />C Audit <br />• :MTS <br />Kittitas County Ruditor <br />..JCS _ p I lllilll 111111 111 11111111111 111111 111 lII IIII 111111111111111111f 11111 1111 1111 <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): <br />+, i°.k i �.-1•':aC'4� i !f � u P.J^ : �.� i Z�"��:Y'�� �..ii"4 ! S <br />2- Date of Birth: G -4 - C 1 1` t -t L. <br />3. Phone #: (Home):( 1 (Work): (� <br />4. Address (include former address if at present address for less than 6 months): <br />5. Date of Incident: C• k <br />Lc -'On i <br />6. Location of Incident: <br />A`i0 <br />.Page 1 of 3 <br />