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Department of <br />Revenue <br />Washington State REAL ESTATE EXCISE TAX AFFIDAVIT <br />This form is you receipt <br />PLEASE TYPE OR PRINT CHAPTER 82.45 RCW -CHAPTER 458-61 A WAC when stamped by cashier. <br />THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED <br />�.. o....xo,. -ion. <br />Mailing Address 411 North Ruhy Streef Suite 1 �Ii Ma111, Address 119 West First Street <br />City/Stat&Zip Ellenshura WA 98996 <br />0.00 <br />m <br />City/Statsezip Cie Eldon, WA 98922 <br />Exemption Claimed (deduct) S <br />0.00 <br />Phone No. (including area code) (509) 962-7523 <br />0.00 <br />Excise Tax : State $ <br />Phone No. (including area code) 509)674674- 269 <br />Send all property tax correspondence to: O Same as Buyer/Grantee <br />List all real and personal property tax parcel amount <br />List assessed values) <br />0.00 <br />numbers - check box if personal property <br />0.00 <br />Name <br />Mailing Address <br />City/State/Zip - <br />Phone No. (including <br />QStreet address of property. No Address Assigned Cie Etna WA <br />This property is located in Kittitas County <br />❑ Check box if any of the listed parcels are being segregated from another parcel, are part of a boundary line adjustment or parcels being merged. <br />Legal description of property (if more space is needed, you may attach a separate sheet to each page of the affidavit) <br />Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14, Block 1, Connels Addition to Cie Elum, recorded in Book 2 <br />of Plats, Page 21, records of Kittitas County, Washington <br />Select Land Use Cadets): <br />IBI-Widavaop land Ilan only) <br />enter any additional codes: <br />(See back of last page for instructions) <br />YES NO <br />Was die seller receiving a property tax exemption udeferml ander, ❑ O <br />Juptas &Cif,, 84 37, or 8438 RC1' munprofit otgartRation, senior <br />Itum ordisabled person, homwxmerwith limited mean•)? <br />YES NO <br />Is thispropaty, designed as finest land per chapter &L33PCW? ❑ O <br />Istltispmperyclassifiedascmra m(opmsp=,fa and ❑ IZI <br />agricultural, atimber) land per chapter 84_;4 RCW? <br />Is tins Property receiving spnial valuation as h(staical property ❑ t] <br />per chapter 8.3.25 RCW? <br />Irony answers are yes, ample• as Retracted below. <br />(1) NOTICEOFCONTENUANCE (FOREST LANDORCORRENT USE) <br />NEW OWNER(S): To continue the current designation as forest land or <br />classification as current use (open space, farm and agriculture, or timber) land, <br />you most sign on (3) below. The county assessor most than determine ifthe <br />land transferred continues to qualify and will indicate by signing below. Ifthe <br />land no longer qualifies or you do not wish to continue the designation or <br />classification, it will be removed and the compensating or additional taxes will <br />be due and payable by the seller or transferor at the time crank. (RCW <br />84."13.140 or RC1i- 84.34.108). Prior to signing (3) below, you may contact <br />you local comity assessor for more information. <br />This land []does ❑does not qualify for continuance <br />DEPUTY ASSESSOR DATE <br />(2) NOTICE OFCOMPLIANCE(HISTORIC PROPERTY) <br />NEW OWNER(S): To continue special valuation as historic property, <br />sign (3) below. Ifthe new owners) does not wish to continue, all <br />additional tax calculated pursuant to chapter 84.26 RCW, shall be due and <br />payable by the seller or transferor at the time of sale. <br />(3) OWNERS) SIGNATURE <br />PRINT NAME <br />List all personal properly (tangible and intangible) included in selling <br />price. <br />N/A <br />If claiming an exemption, list WAC number and reason for exemption: <br />WACNo.(Section/Subsec(ion) WAC458-61A-205(1) <br />Reason for exemption <br />Transfers from Governmental Entities <br />Type of Document Quitclaim Deed <br />Date of Document <br />Gross Selling Price $ <br />0.00 <br />*Personal Property (deduct) $ <br />0.00 <br />Exemption Claimed (deduct) S <br />0.00 <br />Taxable Selling Price $ <br />0.00 <br />Excise Tax : State $ <br />0.00 <br />0.0025 Local $ <br />0.00 <br />*Delinquent Interest: State $ <br />0.00 <br />Local S <br />0.00 <br />*Delinquent Penalty S <br />0.00 <br />Subtotal $ <br />0.00 <br />*State Technology Fee S <br />5.00 <br />*Affidavit Processing Fee S <br />Total Due $ <br />10.00 <br />A MINIMUM OF $10.001$ DUE IN FEE(S) AND/OR TAX <br />*SEE INSTRUCTIONS <br />I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. <br />Signature of Signature of <br />Granlor or Grantor's Agent Grantee or Grantee's <br />Name(print) CoryWright Name(orin0 <br />Date & city of signing: <br />Date & city of signing: <br />Perjury: Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a maximum term ofnct more than five years, or by <br />a fine in an meant fixed by thecoun ofnot more than five thousand dollars ($5,000.00), or by buthanprisimmusit andfi (RCW 9x20('04 IC)) <br />REV is 0001 a (W/06/17) THIS SPACE- TREASURER'S USE ONLY COUNTY TREASURER <br />