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RaTuHtit@ <br />Woshington Stote <br />Fonrrl 64 0100 <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.s2.070. <br />i 27 rj <br />ln accordance with RCW 84.52.020, 1 Dale Scott Olander Wame),Treasurer ffiile),;o, Kittitas county Public Hospital District No. 2 @istrict name), <br />do hereby certify to the Kittitas Name of county) county legislative authority <br />that the Board of commissioners (commissioners, council, Boord, etc.) of said district requests <br />that the following levy amounts be collec1.6 in 2022 (Year of cotlection) as provided in the district's <br />budget, which was adopted following a public hearing held on Lr.'15-2o2L pate of public heortng). <br />lar levies <br />Excess levies <br />*Examples of other levy types may inc ude EM5, 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 the 'bther" o ptions. <br />Signature:Date: <br />EMS <br />Total certified levy request <br />amount, which includes the <br />amounts below <br />s 900,000.00 $ aso,ooo.oo <br />Administrative refund a mount $ 13.e7 <br />Non-voted bond debt amount <br />Other* <br />Levy General levy Other levy* <br />Totalcertified levy <br />request amount, <br />which includes the <br />amounts below. <br />L-l <br />Administrative refund <br />amount <br />Other* <br />General <br />(rr/a for school <br />clistricts) <br />Enrichment <br />( sc hool <br />districts only) <br />Levy Bond Cap. project <br />Other lev <br />To regqqs-t this document in an alternate format, p.legse complete the form dor.wa.gov/AccessibilityRequest <br />or call 360-7A5-6705. Teletype (TTY) users please dial 71 1. <br />REV 54 0L0O (8/27/2Ll page 1 oft