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RO', sC ITOR, ly-L— <br />COIVW-SSIONERS <br />DI;PAIt'I'MEAfT L <br />INSURANCE <br />Return to: <br />04/12/2018 02:20:26 PM 201804120025 <br />$0.00 Pawl of 7 <br />Claims Against County/ris/miso PROSECUTOR <br />Krltitas. County Auditor <br />111111111111111 1 111,1111111111111111111111111111111111111111111111111111111111 <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />County Auditor <br />205 W 5th Ave, Suite 105 <br />Ellensburg, WA 98926 <br />509-962-7504 <br />Instructions: <br />Please read the entire form before completion. Fill out each question as completely as possible, <br />to the best of your ability. Do not hesitate to use the back side of this form if you need more than <br />the space provided. An incomplete response may delay the processing of your claim. <br />1. Name (Incl ding spouse, if married): <br />2. Phone (Home): (,50q -q99 -a'1 aR (Work): <br />3. Address (include former address if at present address for less than 6 months): <br />grol S+w-a--r3e 26 VILejSburq. t.JA R$q" <br />Physical <br />P6 Qoyc 445 E14�sb��y , �l W ag�ia 6 <br />Mailing <br />4. Date of Birth: 101-7/ / 0 q 0 <br />Date and Time of Incident: <br />Wal /8O1'; ee,+,.wen 17:30ow, o a : 00P w� <br />6. Location of Incident: <br />--1x00 Block ocn V MA+-anuw% Q (,900MV% TAO owrp4ss <br />aid cewce Lake <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />