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Rai-fftit(e <br />Woshington Stote <br />Form 54 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 84.52.070, <br />Date: t t <br />}l0l/ 22 "ri <br />ln accordance with RCW 94.52 .OZ0,l James L DeVere (Name), <br />Mayor ffiile), yo1" Town of South Cle Elum (District name), <br />do hereby certify to the Kittitas (Name of county)County legislative authority <br />that the TownCouncil (Commissioners, Council, Boord, etc.) of said district requests <br />that the following levy amounts be collecls6 ;6 2022 (Year of cottection)as provided in the district's <br />budget, which was adopted following a public hearing held on tLlL6l2o2L (Date of pubtic heoring). <br />ular levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construction levies <br />Examples of her amounts may include levy error correction or adjudicated refund amount. Please include <br />a descripti <br />Signature: <br />t ,ro er" options. <br />To req <br />or call <br />u is document in an alternate format, please complete the form dor.wa.gov/AccessibilityRequest <br />360-705-6705. Teletype (TTY) users please dial 7i 1. <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ tgo,ooo.oo <br />Administrative refund amou nt <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 />Administrative refund <br />amount <br />Other* <br />General <br />(n/a for school <br />d i stricts) <br />Enrichment <br />(school <br />districts only) <br />Other levy*IBondCap. projectLevy <br />REV 64 OIOO (8/27/2t)Page 1 of 1