HomeMy WebLinkAbout12-26-2018 - 45123 - Jeremy Logan Sybertz - Claim for DamagesPROSECUMT6 v �- _..�
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Claims Against Ccuntylrislmisc KC PROS
Kittitas County Auditor
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KITTITAS COUNTY CLAIM FOR DAMAGES
Return to:
- -- County Auditor --
205 W 5'h Ave, Suite 105
EIlensburg, WA 98926
509-962-7504
Instructions:
Please read the entire form before completion. Fill out each question as completely as possible,
to the best of your ability. Do not hesitate to use the back side of this form if you need more than
the space provided. An incomplete response may delay the processing of your claim.
1. Name (Including spouse, if married):
2. Phone (Home): N (Work): i(/r
3. Address (include former address if at present address for less than 6 m
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4. Date of Birth:
5. Date and Time of Incident:
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6. Location of Incident:
I of 3
Kittitas County Claim for Damages Form
Revised M012
Filed for Record 12/26/2018 1 2:11:26 PM - Kittitas County, WA Auditor - 201812260036 Page 2 of 3
7. Describe in detail the defect which caused the injury:
8. Describe in narrative form and in detail exactly how the incident occurred:
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9. List the names of all persons involved and contact information, if known.
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10. Was claim investigated by a police officer? /yd
Sheriff State Patrol City Police
11. Description of claimant's vehicle: Make Year
Model:
License No
12. Describe what you did after the accident occurred:
13. Describe the conversations you had, if any, with County personnel during or after the
incident occurred: _ _ -113
2 of 3
Kittitas County Claim for Damages Form
Revised 912012
Filed for Record 12/26/2018 1 2:11:26 PM - Kittitas County, WA Auditor - 201812260036 Page 3 of 3
14. Describe the damages or injuries which you sustained as a result of the incident:
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15. What is the amount of damages claimed? (Include estimates and bills, if available):
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16. How did you identify the County as the party responsible for,.your damage?
17. List the names and addresses of all witnesses to the incident:
18. Are you covered by insurance? PO If yes, who is your insurance agent/carrier?
Dated this Z6 Day of ��C�1M�` , 20J&.
Signature of Claimant
Subscribed and sworn (affirmed) to before me
2016.
Seal
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k: Kittitas County Claim for Damages Form
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