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01/06/2011 03:45:29 PM 201101060027 <br />il)ici. ` ✓ - $0.00Page 1 of 3 <br />Claims Against Countylrislmisc K CO <br />Kittitas County Auditor <br />. - � �_ W�_ I111111111111111IIIIIIIIIIIIuII 11111111111111111111111111111111111111111111 <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: County Auditor <br />205 W 5th, Suite 105 <br />Ellensburg, WA 48926 <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): `',Z/pA,rJ�E' 'A� � W.V <br />r <br />2. Date of Birth: <br />3. Phone#: (Home):( ) _(Work): <br />4. Address (incluo former address if at present address for less than 6 months): <br />5. Date of Incident:_ //? ? / ZOE! <br />6. Location of Incident: Z -o 7` I T - L d44Le-y <br />Page 1 of 3 <br />