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DEPARTMENT <br />OF REvENUE <br />WASHINGTON STATE 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, I, _D:::....::e~bb~i:..::e-=L::..:..-=L::..=e:=:e ______________ _ <br />(Name) <br />Clerk/Treasurer for ____ ---==C~it:.l.y.....:o::..:f__=K..:;i:..::tt:.:.;it:.::a~s ____ , do hereby certify to <br />(Title) (District Name) <br />the ____ ---::.K;::.:ic:.;ttc:.;it;.::a.:;..s _____ County legislative authority that the _C.::....:..;:.ity"----"C--'o_u....;;n..;..cl:.;;.·l ________ _ <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 12/13/2016 <br />(Date of Public Hearing) <br />Regular Levy: $170,000.00 <br />(State the total dollar amount to be levied) <br />Excess Levy: <br />(State the total dollar amount to be levied) <br />Signature: Date: 12/13/16 <br />For tax assistance, visit http://do l".\Va .goorcalll-800-647-7706.Toinquire about the availability of this document in an <br />alternate format for the visually impaired, please call (360) 705-6715. Teletype (TTY) users may call 1-800-451-7985. <br />REV 64 OIOOe (w) (10 /26 /05)