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RaffiffilI@ <br />Woshington Stote <br />Form 64 0L00 <br />DIC -3 <br />Signature <br />; . i...: ., <br />ln accordance with RCW 84.52.020, I Lhor lotl'- Qoe' eala s (Name), <br />S'z*'^e-*ot rJ ffitte),1o, Kittitas county Fire Oistrict #4 District nsme), <br />do hereby certity to the Kittitas (Name of county)county legislative authority <br />that the commissioners (commissioners, council, Board, etc.) olsaid district requests <br />that the following levy amounts be collesls6 1n 2022 fteor af callectionl as provided in the district,s <br />budget, which was adopted following a public hearing held on I2 - r - 2 ) (Dote of public hearing). <br />lar levies <br />Excess levies <br />+Examples of other I eW 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 />a description when using r"options <br />Levy Certification <br />submit this document, or something similar, to the county tegislative <br />authority on or before l{ovember 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 assessot. <br />This form is not designed for the certification of levies under RCW g4.5A.070. <br />Date: lL-A-Ll <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ 41,000.00 <br />Administrative refund amount <br />Non-voted bond debt amount <br />Other* <br />Levy General levy Other levy+ <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />L <br />Administrative refund <br />amount <br />Other* <br />General <br />{n/a f or school <br />distri cts ) <br />Enrichment <br />(scl-rool <br />districts only) <br />Other <br />Cap. projecttevvBond <br />To regqe{ thls document in an alternate format, p.l_e?$ complete the form clo_r,wa,goylAeee-s,s.ibilitynegueg <br />or call 360-7056705. Teletype (TTY) users please dial 7t l. <br />REV 64 ot00 18127/2L) page 1 of 1