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Prosecutor v <br />i Commissioner <br />Department <br />Insurance C. _ <br />01/19/2023 04:33:45 PM 202301190022 <br />$0.00 Page:t or 3 <br />Claims Against County/rls/mist CAMARATA <br />Kittitas County Auditor <br />1111111111111111111111113 11111111111111111111111111111111111111111111111 IN <br />K=rrAS COUNTY CLAIM FORDAMAGES <br />Return to: <br />County Auditor <br />205- W 5h Ave, 811ite 105 <br />Ellensburg; 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. M incomplete response may delay the processing of your claim:. <br />Name'(Including spouse, if married)¢ <br />Gene'Camarata <br />2. Phone (Horne): ( ) (Work): ( ) <br />3. Address (include former address if at present address for,less than.6 months): <br />Portland, Orgon,.If necessarywill challenge this question on privacy .and harassment} <br />by Kittitas. Colin-concerins at -a later time. <br />m"i"r General Delivery, Ellensburg, WA 98926 E -Mails gonescases@yahoo.com <br />yahoo.com. <br />GeneCamarata@gmail.com <br />4: Date of.Bixth: I December 26, .1.9.59 (One. or the other, or both.) <br />. - <br />(E-mail much preferred to U.S. Postal Service mall.) <br />5. Date and Time of Incident: — <br />March 16, 2016, at 3:45 PM. and/or days later still to be ascertained; I, Gene Camarata, <br />became aware of the incident on the afternoon of January 21, 2022. <br />6: Location of1ficideht: . <br />Kittitas County Clerk's Office, 205 W 5th AVE .Suite 210,,Ellensburg WA 98926 and ` <br />very likely at Daily Record, 401 N. Main Street, Ellensburg, WA 98926 • <br />1 of 3 <br />Kittitas County: Claim for Damages Form <br />Revised 9/2012 <br />