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Of <br />01/06/2011 03:45:28 PM 201x9101060025 <br />$000 <br />asgtinstYCRudttorls/misc <br />st <br />KittitK CO <br />1111111111111111111141111111111111111111 1111111111111111111111111111111111111111 <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 />2. Date of Birth: /0/x- 7 /i50 5 <br />3. Phone k (Home): (sem l (Work): 6,11Y -7 -J <br />4. Address (include former address if at1resent address for less than 6 months): <br />5. Date of Incident: 4-) <br />6. Location of Incident: S�1 _ /-:CLG <br />Page 1 of 3 <br />