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PROSEOU71f3R__T ` <br />CODIMSSIONERS U <br />DEPAMIEvT VJ, 201506110026 <br />06/11/2015 03:43:51 PM page:1 of 3 <br />INSURANCE $0.00 <br />Claims Against County/r1slmisc K CO PROSEC <br />Kl t t i tas County Rudi foriii III milli 1111 111 <br />1111111111111111111111111111111111 IN 11111111111111111111111111111 ITIII 1 <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5.1h Ave, Suite 105 <br />Ellensburg, WA 98926 <br />509-962-7504 <br />Instructions: <br />Please read the entire form before completion. Fill out each question as completely as possible, <br />to the best of your ability. Do not hesitate to use the back side of this form if you need more than <br />the space provided. An incomplete response may delay the processing of your claim. <br />1. Name (Including spo se, if married): <br />IYIPGE Co�G��y,(�(' <br />2. Phone (Home):�4I 306 If&I rJ ) (Work): &V&f Lf&bf j -X V <br />3. Address (incl dg former address if at present addres§ for lessthan 6 months): <br />t 11G, USM �l <br />26Y7- <br />Physical <br />Mailing <br />4. Date of Birth: <br />5. Date and Time of Incident: <br />06-08- 115 15trD 40145 <br />6. Location of Incident: <br />`aovld` 4e,- Ok&,5 ice KVtq <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />