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RDep,artment 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::.I:..:.;iz==a:.::b~et=h:...:Ac..::..:..:.lIg""o:..:o:..;:d=----___________ _ <br />Treasurer , for <br />(Title) <br />(Name) <br />Kittitas County Public Hospital <br />District N 0.1 <br />(District Name) <br />, do hereby certify to <br />the Kittitas County legislative authority that the Board of Commissioners --------~~~=-----------(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 11-08-2016 <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 />(State the total dollar amount to be levied) <br />Refund Levy: $25,000.00 <br />(State the total dollar amount to be levied) <br />Signature: Date: __ '......:....' 1'6_11 Ce~_ <br />To 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 DIODe (w) (2121/12)