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RDepart men t of (~ <br />evenue ""' Levy Certification <br />!Ri ~©~O ~;g ~ <br />Washington State <br />KIHITAS COUNTY <br />BO/\RO OF EQU,;' Z"J l n~J <br />Submit this document to the county legislative authority on or before November j O 01 fhe yea l' prece(JilltF <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~)jz=a==b""et:.:::bc....:.A..:.;I~lg:>.:o"",o..::cd ___________ _ <br />Treasurer , for <br />(Title) <br />(Name) <br />Kittitas Co un ty Public Hospital <br />District No.2/EMS <br />(District Name) <br />, do hereby certify to <br />the ____ ....:.IK.:.=itt:.;;I:.;;·ta::;;;s~ ____ County legislative authority that the Board of Co mmissi on ers <br />(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 11/10/16 <br />(Date of Public Hearing) <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: $20,000.00 <br />(State the total dollar amount to be levied) <br />Signature: ~ Date: ~~{ \ \ /1 Q! <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) 705-6718. For tax assistance, call (360) 534-1400. <br />REV 64 DIODe (w) (2/21/12) <br />f