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D epartment of @ Revenue ~ <br />Washington State <br />Levy Certification <br />Submit this document to the county legislative authority on or before November 30 ofthe 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, -'E=ry:...<...::n:....:Ac.=..:....:. M=ic:;.:;a;:.:l1~ef=--____________ _ <br />(Name) <br />__________ D~is~tr_i~ct~S~e~c~re~t-'ruy~---------J,for <br />(Title) <br />__ -,K::.;::.:itt=i=ta=s~C~o:..:un==:::.ty~F.:.:ir..::.e:-=D:...:i:..:.str=ic:..:.t....:..7 __ ----.:, do hereby certify to <br />(District Name) <br />the Kittitas County legislative authority that the Fire 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 11/28/16 <br />(Date of Public Hearing) <br />Regular Levy: $1.389,078.31 <br />(State the total dollar amount to be levied) <br />Excess Levy : <br />(State the total dollar amount to be levied) <br />Refund Levy: $30,000.00 <br />(State the total dollar amount to be levied) <br />Date: --'-/):...L..-} U-----"--{2fJ_I---=--V _ <br />NOV 30 2016 <br />1., _ <br />, 11.-• I <br />J ask about the availability ofthis 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)