HomeMy WebLinkAbout05-07-19 Sherley ClaimPROSECUTO
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Claims Against Countytrlslmiso KCPA
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KITTITAS COUNTY CLAIM FOR DAMAGES
Return to:
County Auditor
205 W 5's Ave, Suite 105
Ellensburg, 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.
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Phone (Home): ( 501 ST1 ,1541) (Work): ( L�'YIP-� )
Address (include former address if at present address for less than 6 months):
Mailing
Date of Birth:
Date and Time of Incident:
Location of Incident:
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1 of 3
Kittitas County Claim for Damages Form
Revised 912012
Filed for Record 05/07/2019 03:51:11 PM - Kittitas County, WA Auditor - 201905070021 Page 2 of 4
Filed for Record 05/07/2019 03:51:11 PM - Kittitas County, WA Auditor - 201905070021 Page 3 of 4
Filed for Record 05/07/2019 03:51:11 PM - Kittitas County, WA Auditor - 201905070021 Page 4 of 4