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01/06/2011 03:45:29 PM 201101060030 <br />$0.047 Page 1 of 4 <br />Claims Against Countylrlslmisc K CO <br />Kittitas County Auditor <br />111114111111 III 11111111 I1111111111111111111111111111111111111111111111114111 <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 />S <br />2. Date of Birth: 3 ` )-LA — .VA Lt q <br />30,f_ l0 7y— Zcf, <br />3. Phone #: (Home): ( ) _{Work): <br />4. Address (include former address if at present address for less than 6 months): <br />l e,.;a Aue Cie Ltu A-Sk ` 9'92"—ll z3 <br />5. Date of Incident: del• JJ .-� . o o l <br />6. Location of Incident: o6 00 S tne <br />Page 1 of 3 <br />