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RDepartment of (@ evenue ~ Levy Certification <br />v' /"",/ {P rt/~ vJ <br />Washington State DEe i 5 7016 <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 ~$sessor. <br />In accordance with RCW 84.52.020, I, -=.C.:,:h:..;ri.::..s ..=C-=u:.:,:t1:.:J:ip::.....-_____________ _ <br />(Name) <br />____________ ~S~e~cr~e~ta~ry~ ___________ ,for <br />(Title) <br />__ --"K...::.i:..;;,(tI;";,·t;;..;;;a~~t)'_u....;;n,;";ty"__"_F'_ir..;"e.....;.D....;,i..:...;st,;;,,ri;..:.c,;;,,t #_4 __ , do hereby certity to <br />(District Name) <br />the Kittitas County legislative authority that the Commissioners --------~~~~---------...::.~~~~~~---------------(Name of County) (Commissioners, Council, Board , etc.) <br />of said district requests that the following levy amounts be collected in 2017 v.:s provided in the district's <br />(Year of Collection) <br />budget, which was adopted following a public hearing held on 12/05/16 V: <br />(Date of Public Hearing) <br />Regular Levy: 26,000.00 <br />(State the total dollar amount to be levied) <br />Excess Levy: <br />(State the total dollar amount to be levied) <br />Refund Levy: <br />(State the total dollar amount to be levied) <br />Signature: Date: / z../5' It () <br />I <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 OIOOe (w) (2/21112)