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RavEh"iid (? <br />Woshrngton Stote <br />Submit this document to the countSr legislative arthority 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 84.52.020,1,Dale Scott Olander <br />(Name) <br />Kittitas Co.unty Public Hospital , do hereby certifu to <br />District No. I <br />Treasurer <br />Levy Certification <br />(District Name) <br />County legislative authority that the Board of Commissioners <br />, for <br />the <br />(Title) <br />Kittitas <br />(Name of County)(Commissioners, Council, Board, etc.) <br />of said district requests that the following levy amounts be collected in 202r as provided in the district's <br />(Year of Collection) <br />budget, which was adopted following a public hearing held on wzzr2az} : <br />(Date of Public Hearing) <br />Regular Levy $25.000.00 <br />(State the total dollar amount to be levied) <br />Excess Levy: <br />(State the total dollar amount to be levied) <br />Refund Levy: <br />(State the total dollar amount to be levied) <br />Signature i>.,r.2"#Date 'z TJ.LO <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 assisrance, call (360) 534-1400. <br />REV 64 0100e (w) (2lzllt})