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RDeparlmenl of ra even ue ~~ <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, I, ....;E=I iz=a:..:bc.::.e.::,th:....:A....:..:..:.lIgc.;o:..:o:.,:d'--___________ _ <br />Treasurer , for <br />(Title) <br />(Name) <br />Kittitas County Public Hospital <br />District No.1 <br />(District Name) <br />, do hereby certify to <br />the Kittitas County legislative authority that the Board ofCoTl1m issioners ----~~~-----(Name of County) (Commissioners, Council, Board, elc.) <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: $25,000.00 <br />(State the total dollar amount to be levied) <br />Excess Levy: $1.355.187.50 <br />O[e Z 1 ?n16 <br />(State the total dollar amount to be levied) <br />Refund Levy : $8,676.54 (revised 12-14-16) <br />(Slate the total dollar amount to be levied) <br />Signature: ~.~JL ~-D Date : \ ~(. ("<--re::{ Cp <br />To ask about the availability of this publication in an alternate fonnat 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 DIODe (w) (2/21112)