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Department of <br />Revenue PC <br />Washington State <br />Levy Certification <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, Elizabeth Allgood <br />(Name) <br />Treasurer , for Kittitas County Public Hospital , do hereby certify to <br />District No. I <br />(Title) <br />the Kittitas <br />(District Name) <br />County legislative authority that the -Board of Commissioners <br />(Name of County) (Commissioners, Council, Board, etc.) <br />of said district requests that the following levy amounts be collected in 2017 as provided in the district's <br />(Year of Collection) <br />budget, which was adopted following a public hearing held on 11-08-2016 <br />(Date of Public Hearing) <br />Regular Levy: <br />Excess Levy - <br />Refund Levy: <br />$25,000.00 <br />(State the total dollar amount to be levied) <br />$1.355,187.50 <br />(State the total dollar amount to be levied) <br />$8,676.54 (revised 12-14-16) <br />(State the total dollar amount to be levied) <br />Signature: �2_ �J <br />Date: ` I Z� <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 />