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• <br />4 <br />09/07/2018 09:38:09 AM 201809070003 <br />$0.00 Paga:1 of 3 <br />Claims Against County/ris/mist BAKER <br />1111111 NIE 11111111 IIIII rluil"I II II 1111111111111111111111111111111111 1111 <br />PROSECUTOR-- <br />COMSSIOiQER3 �. <br />nEPAtrv04T—W�-4 ..--. <br />INSURANCE <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />County Auditor <br />205 W 5'h Ave, Suite 105 <br />Ellensburg, WA 98926 <br />509-962-7504 <br />Instructions: p <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. NNie (Including spquse, if married): <br />2. Phone (Home): d Z (Work): ( } <br />3. - Address (include former address if at present address for less than 6 months): <br />Mailing - <br />4. Date of Birth:.y,Lz1�� <br />5. Date and T' e of Incident: <br />o U - j :00 <br />0 <br />on of Incident: <br />0/7 <br />.:&411d .. , , , <br />on H47yJw.,a!o <br />1 of 3 <br />Kitlitas County Claim for ]damages Form <br />Revised 92012 <br />