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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 g4.52.070. <br />er"options. <br />To req is document in an alternate format,p lease complete the form dor.wa. gov/Access i bi I ityReq uestor cal 7 05-67 05.Teletype (TTY) users please <br />RafiffilE(e <br />Washington Stote <br />Form 64 0100 <br />i!0v 16 tii!,.l <br />ln accordance with RCW 94.52 .O2O,l John Sinclair (Name), <br />Fire chief ffitle),16, Kittitas county Fire District z lDistrict name), <br />do hereby certify to the K'ttitas (Name of county)county legislative authority <br />that the Board of Fire commissioners Qommissioners, council, Boord, etc.) of said district requests <br />that the following levy amounts be collecls6 ;n 2022 (Year of cottection)as provided in the district,s <br />budget, which was adopted following a public hearing held on ttlL6/2021 (Date of pubtic hearing). <br />ular levies <br />Excess levies <br />* Examples of other levy types may include EMS, school d istrict tra nsportation, or construction levies. <br />Examples of other amounts v clude levy erro r correction or adjudicated refund amount. please include <br />oate: /@ '/zt d <br />a description w <br />Signature <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />S 5,zoo,ooo.oo <br />Admin istrative refund amount <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 />S ass,ooo.oo <br />Administrative refund <br />amount <br />Otherx <br />General <br />(n/a for school <br />d istricts) <br />Enrichment <br />(school <br />districts only) <br />Other levy*IBondCap. projectLevy <br />REV 64 0rOO (8/27/27) <br />d ial711 <br />Page 1 of 1