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03/25/2016 04:59:08 FM 201601250075 <br />$0.00 Page:i of 4 <br />Claims Rgainst Countylrlstmise PROSE UTOR <br />KittitasCounty Auditor <br />111111111111111111111111111111111111111111111111111111111111111111,111111 <br />corrlM-WONT } <br />Dr3PARrVMT G <br />INSURANCE - - <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />-205 W 5h 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 />I. Name (Including spouse, if married): <br />2_ Phone (Horne):( 501 IA5 I I �) (work): {V W M) <br />3. Address (include former address if at present address for less than 6 months): <br />£ny., r� k mill M . �wsLu <br />- Mailing - <br />4. Date of Birth: jmm--� <br />5. Date and Time of Incident: r 1 <br />A <br />1 of 3 <br />Kittitas County Claim for Damps Form <br />Revised 912612 <br />