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RDepa rtme nt of ~ evenue ~ <br />Washington State <br />Levy Certification NOV 2 6 '~/ <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, <br />(Name) <br />__ f ·_,re~C,._ .. / _.e ___ f __ __,,for <br />(Title} <br />]( }~ ift?i. s· ~~lfl'-f; h 'rc., J),sJ }. do hereby certify to <br />(District Name) <br />JG }l; k~ County legislative authority that the --'----------the f,'~ Ctlm,n/r s/'(Y) fJrs <br />(Name of County) (Commissioners, Council, Board, etc.) <br />of said district requests that the following levy amounts be collected in JO I If as provided in the district's <br />(Year of Collection) <br />budget, which was adopted following a public hearing held on JI -d-1 -If : <br />(Date of Public Hearing) <br />Regular Levy: <br />(State the tofu I dollar amount to be levied) <br />Excess Levy: <br />(State the total dollar amount to be levied) <br />Refund Levy: <br />(State the total dollar amount to be levied) <br />Signature: 13,-v.~~ .!2 ~_% Date: JI -J-1 -I f> <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 0I0Oe (w) (2/21/12)