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Ravffi[:[@ <br />y''&ishingao,r 5t.rle <br />Levy Certification <br />Submit this document, or something similar, io 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 />Forrs"l 54 010S <br />)lov 3 t} <br />ln accordance with RCW 84.52.020, 1 Jeannine Lavande (Name), <br />SecretarylFinancial Mgr. (Title),;o; fi$jlgq !o. Fire Protection District e yDistrict nome), <br />do hereby certify to the Kittitas ":r r' (Name of county)County legislative authority <br />that the Board of Fire Commissioners (Commissianers, Council, Baard, etc.) of said district requests <br />that the following levy amounts be colleclsd ;n 2022 (Year of collectian)as provided in the district's <br />budget, which was adopted following a public hearing held on LU23/21 (Dote of public hearing). <br />ular levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construction levies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. Please include <br />a descripti <br />Signature: <br />o <br />To req <br />or call <br />uest <br />36A-7 <br />nw n using the "ot " options. <br />e: ll <br />document in an alternate format, please complete the form dor.wa,govlAccessibilityRequest <br />-67A5. Teletype (TTY) users please dial 711. <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ l+o,ooo.oo <br />Administrative refund a mount $zLo.z7 <br />$ o.ooNon-voted bond debt amount <br />Other*S o.oo <br />Generallevy Other levy*Levy <br />-.IJ <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />S o.oo <br />Administrative refund <br />amount <br />$ o.oo <br />Other*$ o.oo <br />General <br />(n/a for school <br />districts) <br />Enrichment <br />{school <br />distr:icts only) <br />Cap. project <br />Other <br />BondLevy <br />REV 64 ]LAA (B/27/2L)Page L of 1