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3 ;,-JS=U70 TZL . <br />01/06/2011 03:45:29 PM 201101060035 <br />,i `,t a[r11EkSJ� $0.00 Page 1 of 32 <br />Claims Against Countylrls/misc K CO <br />Kitltlitas County Auditor II i <br />_t'r4'i1��1't��. / �, I II�� 11 IIII'I IIII � III IIIIIII IIIII� IIII IIII IIII I I �#1 II VIII III I! III III <br />AUDITORS KnTE Portions of this <br />document pocor quality!or ima-_Ing <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 claire. (� <br />1. Name (Including spouse, if married): T1 l,--kC[.V'A k) <br />2. Date of Birth: t - i S- lC1 54e 5 - r to - Lei 6c 3 <br />3. Phone #: (Home).( ) i�`( Mork): (_j <br />Address (include former address if atresent address for less than 6 months): <br />uF: 3t aA 3o-*� l�� 5E , OA 4b -6Z <br />5. Date of Incident: JCth tt!. q-1,1IQ <br />T t 7i <br />6. Location oflncident: 14 b (�-)UrAj 4 WA VL4 M . � Cee— FIt.LV%4 I �_ <br />WA 6126 zz Q <br />�— <br />Page 1 of 3 <br />