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Ra'"fffit@ <br />Woshington Stote <br />Forrsr 64 0X.00 <br />NOV 27 <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 84.52.070. <br />lt1,g..1991dance with'RCW 84.52.020, I Dale scott olander (Name), <br />chief Financial officer ffiile) ,;ol. Kittitas county Public Hospital District No. 1 pistrict name), <br />do hereby certify to the Kittitas $ame of county) County legislative authority <br />that the Board of commissioners $ommissioners, council, Board, etc.) of said district requests <br />that the following levy amounts be colleclg6 in 2022 ffeor of collection) as provided in the district's <br />budget, which was adopted following a public hearing held on Lal28l2o2l (Date of pubtic hearing). <br />lar levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construction levies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. Please include <br />"other" o ptions. <br />J.^Date: <br />To regqgs_t !!ti: {gqqrnent in an alternate format, please complete the form dor.wa.gov/AccessibilityRequest <br />or call 36A-705-6705.Teletype (TTY) users please dial 71 l. <br />REV 54 OLAI $lT7lztl Page 1 of 1 <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ z5,ooo.oo <br />Administrative refund amount $ 4.zo <br />Non-voted bond debt amount <br />Other* <br />General levy Other levy'FLevy <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />L-J <br />Administrative refund <br />amount $ a,gor.ag <br />Other* <br />General <br />(n/a for school <br />d i str rcts ) <br />Enrichment <br />(school <br />distrrcts only) <br />Other <br />Levy Bond Cap. project <br />*