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RDepanmen l of (~ evenue ~ <br />Washington State <br />NOV 7 1 7n16 <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..:..A..::I~lg2.::0;.::;o=.d ___________ _ <br />Treasurer , for <br />(Title) <br />(Name) <br />Kittitas County Public Hospital <br />District No.2 <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 11110/2016 <br />(Date of Public Hearing) <br />Regular Levy: $1 ,23 0,000 .0 0 <br />(State the total dollar amount to be levied) <br />Excess Levy: <br />(State the total dollar amount to be levied) <br />Refund Levy: $15 .000.00 <br />(State the total dollar amount to be levied) <br />Date: _' ~.:....I--,4' It.......:( ...... tp--- <br />To ask about the availability of this publication in an alternate format for the visually impaired, please call (360) 705-6715. <br />Teletype (TTY) users, please call (360) 705-671 B. For tax assistance, eaU (360) 534-1400. <br />REV 64 OIOOe (w) (2/21112)