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Departmentof Real Estate Excise Tax Affidavit (RCW 82.45 WAC 458-61A) <br />Revenue C Only for sales m a single location code on or afterluly 1, 2022, <br />Washingi State This affidavit will not be accepted unless all areas on all pages are fully and accurately completed. <br />Form 84 ( a This form is your receipt when stamped by Cashier. Please type or print. <br />❑ Check box ifpartialsale, finificari sold. List percentageofownership acquired nextto each name. <br />1 Seller/Grantor <br />Name Kittitas Coun <br />ARn: Board of County Commissioners <br />Mailing address 205 W 5th Avenue Suite 108 <br />City/nate/zip Ellensburg, WA 98926 <br />Phone (including area code) 509-962-7508 <br />2 Buyer/Grantee <br />Name Washington State Department of Ecdo <br />State Trust Water Rights Program <br />Mailing address 1250 W Alder Street <br />City/state/zip Union Gag, WA 98903 <br />Phone (including area code) 509-575-2490 <br />3 Send all property tax correspondence to:0 Same as Buyer/Grantee List all real and persona l property tax Personal Assessed <br />Name parcel account numbers property? values) <br />See attached "Exhibit A" ❑ $ 0.00 <br />Mailing address ❑ $0.00 <br />City/gate/zip ❑ $ 0.00 <br />4 Street address of propert Water Rights OnIVISchnebly Rd Ellensbum WA 98926 _ <br />This property is located in lKlRltas (for unincorporated locations please select your county) <br />❑ Check box if any of the listed parcels are being segregated from another parcel, are part of a boundary line adjustment or parcels beine mcm.d <br />Legal tleson ion of property Jif you need more space attach a separat sheet t h page f the <br />ISee Attached "Exhibit B" <br />JUU - Water or Mineral rights <br />Enter any additional codes <br />(see back of lag page for instructions) <br />Was the seller receiving a property tax exemption or deferral <br />under RCW 84.36, 84.37, or 84.38 (nonprofit org., senior <br />citizen or disabled person, homeowner with limited income)? ❑ yes 0 No <br />Is this property predominately used for timber (as classified <br />under RCW 84.34 and 84.33) or agriculture (as classified under <br />RCW 84.34.020) and will continue in it's current use? R yes and <br />the transfer involves muRiple parcels with di%—t classifications, <br />rompletethe predominate use cakulemr(seeingru�Uom) Oyes ONO <br />6 Is this property designated as forest land per RCW 84.337 Ones ONO <br />Is this property classified as current use (open space, farm <br />and agricultural, or Umber) land per RCW 84.34? ❑ Yes 0 No <br />Is this property receiving special valuation as historical <br />property per RCW 84.267 ❑ 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 />Umber) land, you must sign on (3) below. The county assessor must then <br />determine if the land transferred confinees 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 translator 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 />7 Lin 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/subsecdon) 458-61A-205 <br />Reason for exemption <br />Per Article A of the Washington State Conslitubon, the grantor is a <br />governmental enfity. <br />Type of document Quit Claim Deed <br />Date of document _ <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: gate <br />Total excise tax: state <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 at 3% <br />0.00 <br />Agricu Ito ral and tim bedand A 1.28% <br />0.00 <br />This land: ❑does ❑ does not qualify for <br />Total excise tax: state <br />0.00 <br />continuance. <br />0.0025 Local <br />0.00 <br />Deputy assessor mggnature Date <br />'Delinquent interest: state <br />0.00 <br />(2) NOTICE OF COMPLIANCE (HISTORIC PROPERTY) <br />Local <br />0.00 <br />NEW OWNER(S): To continue special valuation as historic property, sign <br />'Delinquent penalty <br />0.00 <br />(3) below. If the new owner(s) doesn't wish to continue, all additional tax <br />calculated pursuant to RCW 84.26, shall be due and payable by the seller <br />Subtotal <br />0.00 <br />or transferor at the time of sale. <br />'State technology fee <br />5.00 <br />(3) NEW OWNER(S) SIGNATURE <br />Affidavit processing fee <br />5.00 <br />Signature Signature <br />Total due 10.00 <br />A MINIMUM OF $30.0015 DUE IN FEE(S) AND/OR TAX <br />Printname Print name <br />'SEE INSTRUCTIONS <br />I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT <br />Signature of grantor or agent Signature of grantee or <br />Date & city of signing <br />duty in the second degre <br />a fine in an amount fxr <br />To askabout the av <br />REV840001a (5/31/22) <br />Date & city of signing <br />not more than y WWW or by both such confinement and fine (RCW 9A,72.030 and RCW 9A.20.021(1)(c)). <br />publication in an alternate formatfor the visually impaired, please call 360-705-6705.Teletype <br />(TTY) users may use a WA Relay Service by Calling 711. <br />THIS SPACE TREASURER'S USE ONLY COU NTY TREASURER <br />Print on legal size paper. <br />Page i of 6 <br />