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iI".,,., ii Alf � V <br />-: I.4fv2SSfONERSJ. <br />y�TAR'fMENT L <br />.: <br />01/06/2011 03:45:29 PM 201101060031 <br />$O.fl© Page 1 of 4 <br />nt/inst <br />KClaiSittltasgCountyCOu Rudilorlslmisc K GO <br />11111111111111111111111111 mil 1111111111111111111111I 11111 111 i/ I I11I 1111 I I I I <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):-'� -L <br />2. Date of Birth: - 2' 3 <br />3. Phone #: (Home)`5 S (Work): ( ) <br />4. Address (include former addres if It present address for less than 6 months): <br />5. Date of Incident: <br />6. Location of <br />3! l D �h"'Wy� A4 . <br />6/6 <br />Page 1 of 3 <br />