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Dr,.prtrltlcnt ttf <br />Revenue @ 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 34.52,070. <br />V'/.i sh n i:ta t] :;t.ote <br />Fonrn 64 010S <br />lq0v :i $ <br />ln accordance with RCW 84.52.020, 1 leannine Lavande (Name), <br />SecretarylFinancialMgr. (Title), go; Kittilgs Qo. Fire Protection District a lDistrict name), <br />do hereby certify to the Kittitas i '; 'r! (Name of countylCounty legislative authority <br />that the Board of Fire Commissioners (Commissioners, Council, Boord, etc.) of said district requests <br />that the following levy amounts be colleclgd 1n 2022 (Year of collection)as provided in the district's <br />budget, which was adopted following a public hearing held on LU23/21 (Date of public hearing). <br />R ular levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construclion levies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount, Please include <br />a description n using the "oth opfions <br />Signature:1.'5 ,)o J <br />To request <br />or call 360- <br />document in an alternate format, please complete the form dor,wa,govlAcc.essibilityRequest <br />705. Teletype (TTY) users please dial 71 1 <br />ll <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ 34o,ooo.oo <br />Admin istrative refund amount $213.27 <br />Non-voted bond debt amount $ o.oo <br />$ o.ooOther* <br />General levy Other levy*[evy <br />L-J <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />S o.oo <br />Administrative refund <br />amount <br />S o.oo <br />Other*$ o.oo <br />General <br />(n/a far school <br />districts) <br />Enrichment <br />(school <br />distr:icts only) <br />Cap. projectBondLevy <br />REV 64 ArcO 8/27/2L'Page L of L