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PROSECUMT6 v �- _..� <br />COZYMISSIONERS <br />M' PA,27VENT <br />12/26/2018 12:11:26 PM 201812260036 <br />$0.00 Page:i of 3 <br />Claims Against Ccuntylrislmisc KC PROS <br />Kittitas County Auditor <br />11111111 IIIM 11111111111111111111111 IIIIf EIIII 111111111111111111111111 III <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />Return to: <br />- -- County Auditor -- <br />205 W 5'h Ave, Suite 105 <br />EIlensburg, 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 />2. Phone (Home): N (Work): i(/r <br />3. Address (include former address if at present address for less than 6 m <br />[3 [� v. r-z-,Tk A,e . &,e1/,L Gja-)14 k-Av- . Q� <br />-- <br />F31:3 -- <br />Mailing v <br />4. Date of Birth: <br />5. Date and Time of Incident: <br />-moi z n s q_ �e l — ec-� ✓� •� /���z <br />6. Location of Incident: <br />I of 3 <br />Kittitas County Claim for Damages Form <br />Revised M012 <br />