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De parlment of ~ Revenue ~ <br />VVoshington State <br />NOV 22 <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.:.::cliz=:a::.::b:..;;;e.:.;.th:...:A:..;;;.:.::cllg""'o::.;:o;.;::d=--___________ _ <br />(Name) <br />Treasurer , for Kittitas oun ty Public Hospital , do hereby certify to <br />District No. 21 Mal ntc nance Levy <br />(Title) (District Name) <br />the Kittitas <br />(Name of County) <br />County legislative authority that the Board of Commissioners <br />(Commissioners, Council, Board , etc .) <br />of said district requests that the following levy amounts be collected in 2018 as provided in the district 's <br />(Year of Collection) <br />budget, which was adopted following a public hearing held on 11/13i2017 <br />(Date of Public Hearing) <br />Regular Levy: $1 ,275,0.0.0..0.0. <br />(State the total dollar amount to be levied) <br />Excess Levy : $0.00 <br />(State the total dollar amount to be levied) <br />Refund Levy : $0..0.0 <br />(State the totnl dollar amount to be levied) <br />Signature: WJJ ~~ <br />To ask about the availability of this 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) (2/21/12)