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Raffiffiit@ <br />Washington Stote <br />Fornr Sd S1.00 <br />NOV 18 <br />Levy Certification <br />submit this document, or something simirar; to the county regisrativeauthority on or before November 3b of the year preceding the year in whichthe levy arnounts are to be collected. <br />Courtesy copy may be provided to the county assessor. <br />This form is not designed for the certification of revies under Rcw g4.52.070. <br />ln <br />Signature: <br />To request <br />or call 360- <br />this <br />7Q5-670s. <br />do hereby certify to the K; ll-, lo"S <br />that the $t arfi <br />that the following levy amounts be collected i AD?u <br />(Name), <br />nt'] i:;re D;1 | @istrict name), <br />(Nsme of county)County legislative authority <br />(Com m iss ion e rs, Cou n ci l,Board, etc.) of said district requests <br />(Year of collection) as provided in the district,s <br />yfr':|t;"with RCW 84.s2.020, t /rarV <br />(ritte),# K i\l; <br />n <br />budget, which was adopted following a public hearing hel don It -l'7 - }0;l (Date of pubtic hearins). <br />ular levies <br />Excess levies <br />Examples of other levy types may include EMS,school district t ransportation, or co nstruction levies.Examples of other amounts m ay include levy error correction or adjudicated refund amount. please includeadescriptionen using the €r" options. <br />Date: ll-17,^+9',), <br />in an alternate format,please com plete the fotr do**"gt*-@ <br />certified levy request <br />amount, which includes the <br />amounts below. <br />Total toq Leo D{ <br />inistrative refund amountAdm <br />on-voted bond debt amountN <br />Other* <br />Totalcertified levy <br />request amount, <br />which includes the <br />amounts below. <br />L,-; <br />Administrative refund <br />amount <br />Other* <br />REV64 OLOO (8/27/21) <br />Teletype (TW)users please dial 71 l. <br />Page 1" of 1