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0,4'SSIONEifS <br />01/06/2011 03:45:29 PM 201101060032 <br />$0 00 Page 1 of 4 <br />Claims Against Countylrls/miso K CO <br />Kittitas County Auditor <br />11111411 I IIII 11111111111111111111111111 ILII 1111111111111111111111111111111111 IIII <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. <br />Name (Including spouse, if married): William & Irmgard McGregor <br />2. Date of Birth: 9/1911938 <br />3. Phone #: (Home):ffl9}6745216 (Work): 20 -497.6902 <br />4. Address (include former address if at present address for less than 6 months): <br />542 Teanawaycres Road - Cie Elum, Wa 98922 (PO Box 841 Cie Elum, Wa 98922 <br />5. Date of Incident: - - 11712009 Through 51312009 <br />6. Location of Incident: 542 Teanaway Acres Road - Cie Elum, WA 98922 <br />Page 1 of 3 <br />