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Rafffflii@ <br />Woshington Stote <br />Form 54 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 84.52.070. <br />tn accordance with Rcw 84.52.020, I Brent Hals Nov 3 0 <br />(Name), <br />Mavor ffitre) , gor, clty of Roslyn , <br />: : (District nome) , <br />do hereby certify to the Kittitas : r;' ,' ftrtoii'i:'6f c:ounty)County legislative authority <br />that the Clty Council (Commissioners, Council, Board, etc.) of said district requests <br />that the following levy amounts be collecls6 in 2022 (Year of collection) as provided in the district's <br />budget, which was adopted following a public hearing held on LUO9l202l @ate of public hearing). <br />lar levies <br />Excess levies <br />*Examples of oth er levy types may include EMS, school district transportation, or construction levies <br />Examples of other amounts may include levy error correcfion or adjudicated refund amount. Please include <br />a descripti <br />Signature: <br />on hen using er" options <br />oate: t\ hO I uraII <br />co ln p I ete th e fo rm dor.wa.gov/Access i b i I ityReq uest <br />1, <br />Page 1 of 1 <br />To reguest this document in an alternate format, please <br />or call 360-705-6705.Teletype (TTY)users please dial 71 <br />REV 64 Or0O (8/27/21]| <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ 238,0@.00 <br />Ad ministrative refund amount <br />Non-voted bond debt amount <br />Other* <br />General levy Other levy*Levy <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />$ 30,649.77 <br />Administrative refund <br />amount <br />Other* <br />General <br />(n/a for school <br />d i stricts) <br />Enrichment <br />(school <br />districts only) <br />Other levy*IBondCap. projectLevy