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Re'-fffi{e Levy Certification <br />submit this document, or something slmilar, to the county legistatlve <br />authority on or before November 30 of the year preceding the year in whlch <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 />NOV ?4 <br />ln accordance with Rcw 84.52.020, I Debble Lee (Nome), <br />clerk/Treasurer (Title),1sr citiy of Kittitas (oistrict name), <br />do hereby certify to the Klttitas (Nome of county) county legislative authority <br />that the ciw of lfittitas councll (commissionerc, council, Boord, etc,) ofsaid district requests <br />that the following levy amounts be colleclg6 in 2o22 ffear of collection) as provided in the district,s <br />budget. which was adopted following a public hearing held on LLlzSlilozL @ate of public hearing). <br />r levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district trans portation, or construction I evtes, <br />Examples of other amounts may include revy error correction or adjudicated refund amount. please include <br />a descri the er" options. <br />Signature:Date:It-t3-21 <br />Woshrngton Store <br />Form 64 0100 <br />Total certified levy reguest <br />amount, which includes the <br />amounts below. <br />$ tgg,ooo.oo <br />Administrative refund amount <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 />Administrative refund <br />amount <br />Other* <br />Ge nera I <br />(n/a for school <br />distrrcts) <br />Enrichment <br />{sc h ool <br />districts on ly) <br />Other levy*IBondCap. projectIevy <br />To request thls document in an alternate format, plslfg complete the form dor..wa.gov/AccessibilitvRequestor call 360-70s-OT05. Tetetype {TTy) users pteaie ai;iti i. <br />REV 64 Ot00 (8127/2tl <br />Page I of 1