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01/06/2011 03:45:29 PM 201101060034 <br />$0.00 Page 1 of 6 <br />Claims Against County/rlslmisc K CO <br />f'vi S,SIONERS " " �-� « K i t t i t as County Auditor 1111 IN <br />��� I llllll lll4�llllilllll1111411111111 Ill <br />_ Portions of thin <br />k}C document <br />Quality <br />for ImaCinp <br />_ t ` <br />K=AS COUN'T'Y CLAIM FOR DAMAGES <br />Return to: County Auditor <br />205 W 5th, Suite 105 <br />Ellensburg, WA 98926 <br />144- e : - +t J <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 delaythe processing��o�of your claim. / <br />1. Name (Including; spouse, if married): ,/!� c cp'4i AeV c/2 o S <br />2. Date of Birth: <br />3- Phone#: (Home): (YQ L_7y- ork): (_ ��O( - o�sIr <br />4. Address (include former address if at present address for less than 6 months): <br />(Adv%.L6/, I2-90 4')1.44rr- D e)V*r . / /AC- CAepn - Li/A c <br />5. Date of Incident -v//27 09, 9 <br />6. Location of Incident: -1h W C� L4ALZ y -e— . ch Elgin . I�✓A eAj <br />Page 1 of 3 <br />