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Department a'Pc <br />Real Estate Excise Tax Affidavit (RCW82.45WAC458-61A', <br />Revenue <br />Only for sales In a single location code on or after,Wy 1, 2022. <br />WmhmgLm State <br />This affidavit will not be accepted unless all areas on all pages are fully and accurately completed. <br />Form 840001a <br />This form is your receipt when stamped by cashier. Please type orprint. /w <br />0Checkboxifpartialsale,indicate% sold. <br />1 Seller/Grantor <br />Name rutows uuunly <br />Attn: Board of County Commissioners <br />Mailing address 205 W 5th Avenue, Suite 108 <br />City/state/zip Ellensburg, WA 98926 <br />Phone (including area code) 509-962-7508 <br />3 Send all property tax correspondence to; 12 Same as Buyer/Grantee <br />Name <br />Mailing address <br />4 Street address of prop( <br />This property is located in <br />❑ Check box if any of the <br />List percentage of ownership acquired next to each name. <br />2 Buyer/Grantee <br />Name Washington State Department of Ecology <br />State Trust Water Rights Program <br />Mailing address 1250 W Alder Street <br />City/state/zip Union Gap, WA 98903 <br />Phone (including area code) 509-575-2490 <br />List all real and personal property tax Personal Assessed <br />parcel account numbers property? value(s) <br />Pln of 13678-$434,940 ❑ $ 0.00 <br />❑ so -00 <br />❑ $ 0.00 <br />I(for unincorporated locations Please select your county) <br />another parcel, are part of a boundary line adjustment or parcels being merged. <br />Legal description of property (if you need more space, attach a separate sheet to each page of the affidavit). <br />See Attached "Exhibit A" <br />80 - Water or Mineral rights <br />Enter any additional codes <br />(see back of last page for instructions) <br />Was the seller receiving a property tax exemption or deferral <br />under RCW 84.36, $4.37, or 84.38 (nonprofit org., senior <br />citizen or disabled person, homeowner with limited income)? O Yes 0 No <br />Is this property predominately used for timber (as classified <br />under RCW 8434 and 84.33( or agriculture (as classifed under <br />RCW 84.34.020( and will continue in it's current use? Byes and <br />the transfer involves multiple parcels with differentclasfiations, <br />complete the predominate use alcu,"(we instructions) OYes 0 N <br />61s this property designated as forest land per RCW 84.33? OYes ONO <br />Is this property classified as current use (open space, farm <br />and agricultural, or timber) land per RCW 84.34? ❑Yes O No <br />Is this property receiving special valuation as historical <br />property per RCW 84.26? O Yes 0 No <br />If any answers are yes, complete as instructed below. <br />(1) NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) <br />NEW OW NER(S): To continue the current designation as forest land <br />or classification as current use (open space, farm and agriculture, or <br />timber) land, you must sign on (3) below. The county assessor must then <br />determine if the land transferred continues to qualify and will indicate <br />by signing below. If the land no longer qualifies or you do not wish to <br />continue the designation or classification, it will be removed and the <br />compensating or additional taxes will be due and payable by the seller <br />or transferor a[ the time of sale (RCW 84.33.140 or 84.34.108). Prior to <br />signing (3) below, you may contact your local county assessor for more <br />information. <br />This land: Odoes O does not qualify for <br />continuance. <br />Deputy assessor signature Date <br />(2) NOTICE OF COMPLIANCE (HISTORIC PROPERTY) <br />NEW OWNER(S): To continue special valuation as historic property, sign <br />(3) below. If the new owners) doesn't wish to condnue, all additional tax <br />calculated pursuant to RCW 84.26, shall be due and payable by the seller <br />or transferor at the time of sale. <br />(3) NEW OWNER(S) SIGNATURE <br />name <br />Signature <br />name <br />7 List all personal property (tangible and intangible) included in selling <br />price. <br />If claiming an exemption, list WAC number and reason for exemption. <br />WAC number (section/subsection) 458-61A-205 <br />Reason for exemption <br />Per Article XI of the Washington State Constitution, the grantor is a <br />governmental entity. <br />Type of document Quil Claim Deed <br />Date of document <br />0.00 <br />Gross selling price <br />0.00 <br />'Personal property (deduct) <br />0.00 <br />Exemption claimed (deduct) <br />0.00 <br />Taxable selling price <br />0.00 <br />Excise tax: state <br />5.00 <br />Less than $500,000.01 at 1.1% <br />0.00 <br />From $500,000.01 to $1,500,000 at 1.28% <br />0.00 <br />From $1,500,000.01 to $3,000,000 at 2.75% <br />0.00 <br />Above $3,000,000 M 3% <br />0.00 <br />Agricultural and timberland at 1.28% <br />0.00 <br />Total excise tax: state <br />0.00 <br />0.0025 Local <br />'Delinquent interest: state <br />0.00 <br />Local <br />0.00 <br />'Delinquent penalty <br />0.00 <br />Subtotal <br />0.00 <br />`State technology fee <br />5.00 <br />Affidavit processing fee <br />5.00 <br />Total due <br />10.00 <br />A MINIMUM OF $10.0015 DUE IN FEE(5) AND/OR TAX <br />"SEE INSTRUCTIONS <br />I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING 15 TRUE AND CORRECT <br />Signature of grantor or agent Signature of gra Mee or agent <br />Name (print) Name (print) <br />Date & city of signing Date & city of signing <br />Perjury in the second degree is a class C felony which is punishable by confinement in a state correctional institution for a maximum term of five (,ears or by <br />a fine in an amount fixed by the court of not more than $10,000, or by both such confinement and fine (RCW 9A.72.030 and RCW 9A.20.021 1)(c);. <br />To ask about the availability of this publication in an alternate format for the visually impaired, please call 360-705-6705.Teletype <br />(TTY) users may use the WA Relay Service by calling 711. <br />REve40001a (5/31/22) THIS SPACE TREASURER'S USE ONLY COUNTY TREASURER <br />Print on legal size paper. <br />Page 1 of 6 <br />