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Rf)()pi,r1111<'111nl ~ <br />evenue ·""" t,.V..,rr,1,gu,:1 Sro ,., Levy Certification <br />Submit this document to the county legislative authority on or before November 30 of the year preceding the <br />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 />Che c Ja7'Je_ G on 2.~ J e.s. <br />, for • do hereby ce1tif, to <br />(Title )(District t,/nm ) , <br />the _County legislative authority that the CQ) M.YV\,'-'}g {;t> tlY':5 <br />(Name of County) (Commissioners, Council , Board , etc.) <br />of said district requests that the following levy amounts be collected in <br />(Year of Collection) <br />budget, which was adopted following a public hearing held on <br />(Date of Public Hearing) <br />Regular Levy: <br />(State the total 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: <br />~ZQ_ as provided in the district's <br />To ask about the availability of this publication in an alternate format for the visually impaired, please call <br />(360) 705-6715. Teletype (TTY) users, please call (360) 705-6718 . For tax assistance, call (360) 534- <br />1400. <br />REV 64 0100c (w) (2121/12)