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-Z <br />PROSECUTOR. <br />:.OivUvZSSIONJ <br />ERS <br />DEPARTMENT.1 <br />INSURANCE d1 <br />12/29/2017 11:45:18 AM 201712290016 <br />$0.00 Page:1 of 16 <br />Claims <br />Against <br />Kittitas tYORuditorls/misc KCPROS <br />IIIIII IIIIII III IIII 1111 IIIIIII IIIIII 111111111111111111111111111 <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5th 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 spouse, if married): <br />SLk-L&-n]n e., RP .1y r- (An A 9,ob Rech)r <br />2. Phone (Home): 50q � -y( e (Work): (92-9 _ 4(04 0 <br />3. Address (include former address 'f at present address for less than 6 months): <br />442— RvLLlkboa("%& L� <br />Physical <br />PD. B o x I S burrs v`)A q ?q Z. to <br />Mailing <br />4. Date of Birth: <br />5. Date and Time of Incident: <br />91 3) 201 �- i� �� 30 am <br />6. Location of Incident: <br />lei Fa r -cd rQ <br />9 <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />