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COU SSIONER� <br />01/06/2011 03:45:29 PM 20page geIo 0033 <br />of 4 <br />$0.00 <br />Cl aimsasCounty gainsCKiLtitaudito��slmisc K C <br />11114111111$111111111111111111111 111111111111111111111111111111111111111 <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): W GU it <br />(VIuhd�-1 <br />2. Date of Birth: 3 — 2Z _ `f 0 <br />3. Phone #: (Home):( (Work): () <br />4. Address (include former address if at present address for less than 6 months): <br />_ /sDl f11•t6 s®i� L. , G'le �li��rr 17Yz --4- <br />5. - <br />5. Date of Incident: 1 ~ 9 <br />W <br />6. Location of Incident: P r 1 Sa i ka4ersCK 1Z.6( z) SfL 7 D <br />Page 1 of 3 <br />