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RDepartmentof Real Estate Excise Tax Affidavit (RCW 82.45 WAC 456-61 A) evenue pltly for szles Ir, z single location CCAP "I or after lily 1, 2022, Washington Store This affidavit will not be accepted unless all areas on all pages are fully and accurately completed. Form 84 0001 a This form is your receipt when stamped by cashier. Please type orprint. ❑ Check box if partial sale, indicate % sold. List percentage of ownership acquired next to each name. 1 Seller/Grantor Name Kittitas County Attn: Board of County Commissioners Mailing address 205 W 5th Avenue Suite 108 City/state/rip Ellensburg WA 98926 Phone (including area code) 509-962-7508 3 Send all property tax correspondence to:0 Same as Buyer/Grantee Name City/state/zip 4 Street address of 2 Buyer/Grantee Name Washington State Department of Ecol Stale Trust Water Riahts Proaram Mailing address 1250 W Alder Street Gross selling price 0.00 city/state/zip Union Gap, WA 98903 Phone (including area code) 509-575-2490 'Personal property (deduct) 0.00 Ustall real and personal propertytax Personal Assessed Partial account numbers property? value(s) 865536-$84.000 ❑ $ 0.00 855536-$259.180 ❑ s om 875636-$42,000 ❑ $ 0.00 "'- """'"`"""... Innuhas 1/tor unincorporated locationsplease select your county/ ❑ Check box if any of the listed parcels are being segregated from another parcel, are Dart of a boundary line adi orr—r—„...vi. k.i.e. legal description of property (if you need more space, attach a separateh t to eachp g of the ffid 't) See Attached 'Exhibit A' ICU - Water Or Mineral rlghi5 7 List all personal property (tangible and intangible) included in selling price. Enter any additional codes (see back of last page for instructions) Was the seller receiving a property tax exemption or deferral under RCW 84.36, 84.37, or 84.38 (nonprofit org., senior citizen or disabled person, homeowner with limited income)? ❑ Yes 0 No Is this property predominately used fortimber (as classified under RCW 84.34 and 84.33) or agriculture (as classified under RCW 84.34.020) and will continue in it's current use? byes and the transfer involves mWtipfe parcels wre with different classifications, complete the predominate use calculator(see inetmctiom) OYes laNo 6 Is this property designated as forest land per RCW 84.33? 0Yes 0No Is this property classified as current use (open space, farm and agricultural, ortimber) land per RCW 84.34? ❑ Yes 12 No If claiming an exemption, list WAC number and reason for exemption. WAC number (section/subsection) 458-61A-205 Reason for exemption Per Article Xl of the Washington State Constitution, the grantor is a governmental entity. Type of document Quit Claim Deed Date of document Is this property receiving special valuation as historical Gross selling price 0.00 property per RCW 84.26? ❑ Yes 0 No If any answers are yes, complete as instructed below. 'Personal property (deduct) 0.00 (1) NOTICE OF CONTINUANCE (FORM LAND OR CURRENT USE) Exemption claimed (deduct) 0.00 NEW OWNER(S): To continue the current designation as forest land Taxable selling price 0.00 or classification as current use (open space, farm and agriculture, or timber) land, you must sign on (3) below. The county assessor must then Excise tax: state determine if the land transferred confinues to qualify and will indicate Less than $500,000.01 at 1.1% 0.00 by signing below if the land no longer qualifies or you do not wish to continue the designation or classification, it will be removed and the From $500,000.01 to $1,500,000 at 1.28% 0.00 compensating or additional taxes wi 11 be due and payable by the seller From $1,500,000.01 to $3,000,000 at 2.75% 0.00 or transferor at the time of sale(RCW 84.33.140 or 84.34.108). Prior to signing (3) below, you may contact your local county assessor for more Above $3,000,000 at 3% 0.00 information. Agricultural and timberland at 1.28% 0.00 This land: ❑does ❑does not qualify for Total excise tax: state 000 continuance. 0.0025 Local 0.00 or Deputy assesssignature Date *Delinquent interest: state 0.00 (2) NOTICE OF COMPLIANCE (HISTORIC PROPERTY) Local 0.00 NEW OWNER(S): To continue special valuation as historic Property, sign *Delinquent penalty 000 (3) below. If the new owner(s) doesn't wish to continue, all additional tax calculated pursuant to RCW 84.26, shall be due and payable by the seller Subtotal 0.00 or transferor at the time of sale. *State technology fee 5.00 (3) NEW OWN ERIS) SIGNATURE Affidavit processing fee 5.00 Signature Signature Total due 10.00 A MINIMUM OF $30.0015 DUE IN FEE(S) AND/OR TAX Print name Print name *SEE INSTRUCTIONS 1 CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRER Signature of grantor or agent Signature of grantee Date & city of signing Date & city of signing 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 yyears or by 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.20.02111)(cjf. To ask about the availability of this publication in an alternate for�mdat for the visual) impaired, please call 360-705-6705. Teletype (TTY) users may Ilse the WA Nelay Service by calling 711. REv8400018 (5/31/22) THIS SPACE TREASURER'S USE ONLY COUNTY TREASURER Print on legal size paper. Page 1 of 6