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Depa rtyaeilit. of <br />Revenue,? <br />Washington State <br />Levy Certification <br />DEC 16 ?r?6 <br />Submit this document to the county legislative authority on or before November 30 of the year preceding <br />the year in which the levy amounts are to be collected and forward a copy to the assessor. <br />In accordance with RCW 84.52.020, 1, 7ta Fft.iLCA V�1i1 <br />_ ( ame) <br />,.., <br />L �A r� �r��ecf-i�►-� <br />& CAt � iV *U &O rO�- , for rick& (a4jd jQO), do hereby certify to <br />(Title) (District Name) <br />the M6 County legislative authority that the QU" 4 6AZ L()Yn"fS' dYI&^j <br />(Name of County) (CommissiOners, Council, Board, etc.) <br />of said district requests that the following levy amounts be collected in -:2-O/-] as provided in the district's <br />(Year of Collection) <br />budget, which was adopted following a public hearing held on 0/13/1(, ; <br />(Date of Public Hearing) <br />Regular Levy: f 0(05-, UUD.yD <br />(State the total dollar amount to be levied) <br />Excess Levy: 41 - <br />(State the total dollar amount to be levied) <br />Refund Levy: * � 7 67- 38 <br />(State the total dollar amount to be levied) <br />Signature: {J(�(v d-fe � Date: 1.2 13 I (o <br />To ask about the availability of this publication in an alternate format for the visually impaired, please call (360) 705-6715.. <br />Teletype (TTY) users, please call (360) 705-6718. For tax assistance, call (360) 534-1400. <br />REV 64 0100e (w) (2/21/12) <br />