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Ra*ffil1@ <br />Woshington Stote <br />Form 64 0L00 <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.s2.070.i77 )i <br />ln accordance with RCW 84.52.020, 1 Dale Scott Olander Wame),Treasurer ffiile),fol. Kittitas county Public Hospital District No. 2 pistrict name), <br />' do hereby certify to the Kittitas @ame of county)County legislative authority <br />that the Board of commissioners $ommissioners, council, Boord, etc.) ofsaid district requests <br />that the following levy amounts be colteclg6 1n 2022 (Year of cotlection) as provided in the districtt <br />budget, which was adopted following a public hearing held on 11'1s'2021 @ate of public heartng). <br />lar levies <br />Excess levies <br />*Examples of other levy types rnay i EMS, school district transportation, or construction levies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. Please include <br />a description when the'bther"options <br />Signature:Date: <br />To regqgsJ !ti: {q_.,ltent in an alternate format, please complete the form dor.wa.govlAccessibilityRequest <br />or call 360-705-6705. Teletype (TTY) users please dial 71 1. <br />REV540709 (8/27l2tl pagelofl <br />EMS <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />S goo,ooo.oo $ gso,ooo.oo <br />Administrative refund amount $ 13.e7 <br />Non-voted bond debt amount <br />Other* <br />Levy General levy Other levy$ <br />Totalcertified levy <br />request amount, <br />which includes the <br />amounts below <br />I <br />-Administrative refund <br />amount <br />Other* <br />General <br />ft/a for :chool <br />clistrrcts) <br />Inrichment <br />( school <br />drstricts only) <br />Other I <br />Levy Bond Cap. project <br />.i(