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08/12/2019 02:59:52 PM 201908120064
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Kittitas County Auditor
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KITTITAS COUNTY CLAIM FOR DAMAGES
Return to:
_ County.Auditor -
205 W 51 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.
1. Name (Including spouse, if married): DAVID M. P A u LSLL-
2.
3.
4.
5.
6.
Phone (Home): 5 - (Work):20t -qa
Address (include former address if at present addrels for less than 6 months):
Mailing
Date of Birth: 6
Date and Time of Incident: _ _ M 6 0 Ay JULY 2120171 m. l r 4S D rn
Location of Inci
1 of 3
Kittitas County Claim for Damages Form
Revised 9/2012
Filed for R6pV -Q8&1'212019 02:59:52 PM - Kittitas County, WA Auditor - 201908120064 Page 2 of 4
7. Describe
in detail the defect which caused the injury: T
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Describe in narrative form and in detail exactly how the incident occurred:
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List the names of all persons involved and contact information, if known.
10. Was claim investigated by a police officer? W O
Sheriff State Patrol City Police
11. Description of claimant's vehicle: O 1;VRO LE'r Make 119Y Year
12.
Model: (T2.0 V A t4 License No. L 3 $ `�
Describe what you did after the accident occurred: `r ie *rq ck
13. Describe the conversationsy u d 'f with Co ty personne wring or a er h
in 'dent occurred: " ( R tie
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14. Describe the damages or injuries which you sustained as a result of the incident:
2 of 3
Kittitas County Claim for Damages Form
Revised 9/2012
Filed for Record 08/12/2019 02:59:52 PM - Kittitas County, WA Auditor - 201908120064 Page 3 of 4
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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 ide ify the, unty as t e p res onsible for moue dam e?
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17. List the names and addresses of all witnesses to the incident:
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18. Are you covered by insurance? If yes, who is your insurance agent/carrier?
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Dated this Day of T —,204.
Signature of Claimant
Subscribed and sworn (affirmed) to before me this day of 20.
- SealFNICOLE
y Public
Washington
OSHINSKY
ON# 205250
SION EXPIRES
r 24, 2022
Notary
Residing at
3 of 3
Kittitas County Claim for Damages Form
Revised 912012
Filed for Record 08/12/2019 02:59:52 PM - Kittitas County, WA Auditor - 201908120064 Page 4 of 4
M Gmail
Regarding your estimate
1 message
D. M. Paulsell <dmpaulsell@gmaiil.com>
Safelite AutoGlass <noreply@t.safelite.com> Thu, Aug 8, 2019 at 10:46 AM
Reply -To: Safelite AutoGlass <reply-fe8f16787764037a73-5'16_HTML-597252669-7225942-4285@t.safelite.com>
To: DMPAULSELL@gmail.com
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