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Ra"$uh"ffi |3 <br />Woshington Stote Levy Certification <br />Submit this document to the county legislative arthority on or before Novernber 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, Dale Scott Olander _ , <br />(Name) <br />Treasurer for Kittitas ic Hospital , do hereby certif, to <br />the <br />(Title) <br />Kittitas <br />(DistrictName) <br />County legislative authority that the Board of <br />(Name of County)(Commissioners, Council, Board, etc.) <br />of said district requests that the following levy amounts be collected in 2021 as provided in the district,s <br />(year of Collection) <br />budget, which was adopted following a public hearing held on <br />(Date of Public Hcaring) <br />Regular Levy $25-00 0.00 <br />(State the total dollar amount to bc lcvied) <br />Excess Levy: <br />(State the tottrl dollar amount to bc levied) <br />Refund Levy <br />(State the total dollar amount to be levied) <br />Signature:f)oa.2-#Date:.L 0'Lo <br />To ask about the availability of this publication in an alternate format for the visually impaired, please call (360) 705-6215.Teletype(TTY)users,pleasecall (360)705-6718. Fortaxassistance,call(360)534-14b0. <br />REV 64 0100e (w) (2l2llt2)