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KLICKITAT COUNTY CLAIM FORM This Claim Form is provided solely as an accommodation to claimants and Klickitat County makes no representations as to its legal sufficiency. Responsibility for complying with all requirements of State law regarding claims rests with the claimant. No County employee is authorized to advise a claimant in completing this form or reviewing its sufficiency. Klickitat County expressly disclaims responsibility for any such advice or review. (If more space is needed to answer any items, attach additional sheets and specify the item number). Send or file the completed form and claim to: Klickitat County Risk Management 115 West Court Street Suite 203 Goldendale, WA 98620 State of Washington ) ss County of Klickitat ) , being first duly sworn on oath, says that I am the claimant herein and believe that contents of this claim to be true. I hereby present a claim for damages against Klickitat County, Washington, based upon the following information as required by RCW 36.45.020. 1. Name: (Please Print) 2. My actual and mailing address at the time of presenting and filing this claim is: Address City State Zip 3. My actual address during the six months immediately prior to the time of this claim occurred was: Address City State Zip 4. Home Phone: Work Phone: Message Phone: 5. The incident for which I make claim against Klickitat County occurred on the day of , at AM/PM. 6. The incident occurred at the following location: 7. Describe claim: (Give full details and describe defects causing injury or damage. Attach second page if necessary.) ---PAGE BREAK--- 8. Please list name and address of any and all witnesses: (Please Print. Attach second page if necessary.) 9. The injury or damage I sustained is: 10. The amount of damage I sustained is itemized. (A billing or two estimates of the cost of repairs must be attached to this claim, together with the name of your insurance agency.): $ . DATED this day of , 20 . Claimant's Signature SUBSCRIBED AND SWORN to before me this day of , . Notary Public in and for the State of Residing at My commission expires: