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IY <br />:ft-)NERS <br />01/06/2011 03:45.29 PM 201101060028 <br />$000 Page 1 of 3 <br />Claims Against County/rislmisc K CO <br />Kittitas County Auditor <br />11111111111111111111111111111111111111111111111111111111111111111111 <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: County Auditor <br />las W 5th, Suite 105 <br />Ellensburg, WA 98926 <br />Ing nictlons: <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 />1Name (Including spouse, if married): <br />Q .CJ <br />w <br />. <br />2. Date of Birth: 'C/ �V.� dt"itl3m•� - _ - - fOx <br />3 <br />21 <br />Phone #: (Home): 1 _ —(Work): <br />73r3(include �f ad ess prpt'address for less than 6 months): _ <br />Date of Incident: <br />Page 1 of 3 <br />