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NON 7Z <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 />, lri,ag.copance with.RCW 84.52.020, I Dale Scott Olander Wame), <br />chief Financial officer ffitle),;o, Kittitas county Public Hospital District No. 1 @istrict name) , <br />do hereby certify to the Kittitas fiome of county) county legislative authority <br />that the Board of commissioners (ommissioners, council, Board, etc.) ofsaid district requests <br />that the following levy amounts be collecls6 ;n 2022 ffear of collection) as provided in the district,s <br />budget, which was adopted following a public hearing held on tol28l202l Qate of public hearing). <br />lar levies <br />Excess levies <br />tExamples of other levy types may include EMS, schooldi strict transportation, or construction levies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. please include <br />a description when usi ng the "other" o ptions <br />Signature:Date: I t z- <br />RaTuffliE€a <br />Washington State <br />Forrn 64 03.00 <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />5 zs,ooo.oo <br />Administrative refund a mount $ 4.20 <br />Non-voted bond debt amount <br />Other* <br />Levy General levy Other levys <br />Total certified levy <br />request amount, <br />which includes the <br />arnounts below. <br />L--1 <br />Administrative refund <br />amount $ *,gor.+g <br />Other* <br />General <br />(r.r/a for"sclrool <br />districts) <br />En richment <br />(school <br />districts orrly) <br />Other levLevyBondCap. project <br />;l: <br />To reg99s_t !1ig {99ument in an alternate format, R.legse complete the form dor.wa.gov/AccessibilityRequest <br />orcall 360-705-6705.Teletype (TTY) users pleasebial Zt t. <br />REV 54 oL00 l8/2712U page 1 of 1