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R3iffitit(e <br />Form 64 0100 <br />Signature: <br />To re is document in an alternate format, <br />or cal 7 05-67 0S.Teletype (TTY) users please <br />Levy Certification <br />submit this document, or something similar, to the county legislative <br />authority on or before November 30 of the year preceding the year in which <br />the levy amounts are to be collected. <br />Courtesy copy may be provided to the county assessor. <br />This form is not designed for the certification of levies under Rcw g4.52.070. <br />oate: ^r@ ./Zt ZeZ <br />p.l.e?le co m p I ete the form dor.wa.gov/Accessi bi I itvReq u est <br />dial 71 1. <br />Washington Stote <br />iEov 16 i5?11 <br />ln accordance wilh RCW 84.52 .O2O, t John Sinclair (Name), <br />Fire chief ffitle), ger. Kiftitas county Fire District z (District name), <br />do hereby certify to the Kittitas (Nome of county)county legislative authority <br />that the Board of Fire commissioners $ommissioners, council, Board, etc.) of said district requests <br />that the following levy amounts be colleclsd in 2022 (Year of collection)as provided in the district,s <br />budget, which was adopted following a public hearing held on tLlt6l202l (Date of public hearing). <br />lar levies <br />Excess levies <br />xExamples of other I evy types may include EMS, school d istrict transportation, or construction levies <br />Examples of other amounts lude levy error correction or adjudicated refund amount. please include <br />a description er"options. <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />S 5,7oo,ooo.oo <br />Administrative refund amount <br />Non-voted bond debt amount <br />Other* <br />General levy Other levy*Levy <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />$ 465,000.00 <br />Administrative refund <br />amount <br />Other* <br />General <br />(nla for school <br />d istricts) <br />Enrichment <br />(school <br />districts only) <br />Other levy*rBondCap. projectLevy <br />REV 64 01,00 (8/27 /2t)Page 1 of 1