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RDepartmenl 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-=.et::.:,;h"-=-A-=.:I:..:..<lg=o'-=o-=-d ___________ _ <br />(Name) <br />Treasurer , for Kittitas County Public Hospital <br />District No.2/EMS <br />, do hereby certify to <br />(Title) (District Name) <br />the ____ ~/.:..;K:.:.itt=ita;:.:s"--____ County legislative authority that the Board of Commissioners <br />(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 11/10/16 <br />Regular Levy: $1,174,590.00 <br />(State the total dollar amount to be levied) <br />Excess Levy : <br />(State the total dollar amount to be levied) <br />Refund Levy: _$::;.;O:..:..O;:...;O;....,.-_-,-___ ~-.,.­ <br />(State the total dollar amount to be levied) <br />Signature: <br />(Dale of Public Hearing) <br />Date: <br />ore 2 1 7n1r; <br />fU <br />---------- <br />To ask about the availability ofthis 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 OIOOe (w) (2121112)