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RDeparlmenL of ~ evenue ~ <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;.:.liz=a:.:b:.=e.::.th:...;A~lJgc;o::..:o::..:d=----___________ _ <br />Treasurer , for <br />(Title) <br />(Name) <br />Kittitas Cou nty Pu blic Hospital <br />Distric t No.2 <br />(District Name) <br />, do hereby certity to <br />the Kittitas County legislative authority that the Board of Commissioners --------~~~---------(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 Co lie et ion) <br />budget, which was adopted following a public hearing held on 11/10/2016 <br />Regular Levy: $1 .230.000.00 <br />(State the total dollar amount to be levied) <br />Excess Levy: <br />(State the total dollar amount to be levied) <br />Refund Levy: :-=$:::...O:...;..~OO~_~~ __ ----:----:---;-::- <br />(State the total dollar amount to be levied) <br />(Date of Public Hearing) <br />Signature: ~..Q k ~v-.D Date: <br />DEe 2 1 . <br />---------- <br />To ask about the availability of this pUblication in an alternate format for the visually impaired, please call (360) 705- <br />6715. Teletype (ITY) users , please call (360) 705-6718. For tax assistance, call (360) 534-) 400. <br />REV 64 OIOOe (w) (2/21112)