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R€i?ufr"iH (3 <br />Woshington State Levy Certification <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 arC to be collected and forwarrl a copy to the assessor. <br />ln accordance with RCW 84.52.020,1,Dale Scott C)lander <br />(Name) <br />, for Kittitas County Public Hospital , do hereby certiff to <br />District No.Levy <br />Treasurer <br />the <br />(Title) <br />Kittitas <br />(District Name) <br />County legislative authority that the Board of Commissioners <br />(Name of County)(Commissioners, Council, Board, etc, ) <br />of said district requests that the following levy arnounts be collected in 2021 as provided in the district's <br />(Year ofCollection) <br />budget, wlrich was adopted following a public hearing held on lll09l2} : <br />(Date of Public Hearing) <br />Regular Levy:$1.300.000.00(stut"in@ <br />Excess Levy:$0.00 <br />(State the totsl dollar amount to be levied) <br />Refund Levy:$0.00(state@ <br />Signature i-)"1"A;r AL,^L Date:'zoza <br />To ask about the availability of this publication in an altemate format for the visually impaired, please call (360) 705-6715 <br />Teletype(TTY)users,pleasecall(360)705-6718. Forraxassistance,call(360)534-14b0. <br />REV 64 0100e (w') (2121 I l2',