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k o 01/06/2011 03:45:29 PM 2019101060029 <br />$0,0D <br />Jr Claims Against Countylrlslmisc K CO <br />Kittitas County Auditor <br />1111441111111111111111111111111111111111111111111111111411111111111111111111111 <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: County Auditor <br />205 W 5th, Suite 105 <br />Ellensburg, WA 98926 <br />W - <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 />I . Name (Including spouse, if married): __Vv2 _ ��R- ! K o STE-1.jI�-o <br />2. Date of Birth: 11 _1 v_ y / (0`1 - . __-- <br />4ptcl Li -h `a{s g« z <br />3. Phone t (Home):( ) 2-8 cul (Work): (__) y D L- Co <br />4. Address (include former address if at present address for less than 6 months): <br />L G�_12_ 1 r. o S -TE /.l f� L2,y ! 1 .3L Li U <br />5. Date of Incident: J A -1 -2 -n4 ( 0 <br />6. Location of Incident- <br />CLE 6L-�M <br />Page 1 of 3 <br />1AM <br />