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,00* <br />Department of <br />Revenue (CA <br />Washington State <br />Levy Certification <br />Submit this document to the county legislative authority on or before November 3a0 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, I, <br />(Name) <br />�16' for do hereby certify to <br />J (Title) (Distr' t Name) <br />i r/ <br />the s' County legislative authority that the cY� f7 <br />(Name of County) (Commissioners, Council, Board, etc.) <br />of said district requests that the following levy amounts be collected in 0/6 as provided in the district's <br />(Year of (,ollection) <br />budget, which was adopted following a public hearing held on <br />(Date df Public Hearing) <br />Regular Levy: W/-//, 0QC-) <br />(State the total dollar amount to be levied) <br />Excess Levy: 0 -- <br />(State <br />_(State the total dollar amount to be levied) <br />Refund Levy: ,?/, 97v? <br />(State the total dollar amount to be levied) <br />Signature: Date: <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 />