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Department of Real Estate Excise Tax Affidavit (RCW 62.45 WAC 456-61A) <br />Revenue Onl,f!,!,! <br />for sales in a single location code on or after July 1, 2021 <br />Washington State This affidavit will not be accepted unless all areas on all pages are fully and accurately completed. <br />Form 84 0001 a This form is your receipt when stamped by cashier. Please type or print. <br />❑ Check box if partial sale, indicate% sold. List percentage of ownership acquired next to each name. <br />1 Seller/Grantor 2 Buyer/Grantee <br />Name Kitties County Name Washington State Department of Ecology <br />Attn: Board rCounty Commissioners State Trust Water Rights Program <br />Mailing address 205 W 5th Avenue Suite 108 <br />City/state/zip Ellensburg, WA 98926 Mailing address 1250 W Alder Street <br />Phone (including area code) 509-962-7508 City/state/zip Union Gap, WA 98903 <br />Phone (including area code) 5OM75-2490 <br />3 Send all property tax correspondence to:0 Same as Buyer/Grantee <br />Name <br />4 Street address of prop <br />This property is located it <br />❑ Check box if any of the <br />List all real and personal property tax Personal <br />Assessed <br />parcel account numbers property? <br />value(s) <br />See Attached "Exhibit A" ❑ <br />$ 0.00 <br />❑ <br />$ 0.00 <br />❑ <br />$ 0.00 <br />tfor unincorporated locations please select your county) <br />Rher parcel, are part of a boundary line adiustment or cereals beine mpmpn <br />Le 0=2 <br />l desiri tionm ro 0d if you need mores ace, attach a separate sheet to each page of the affidavit). <br />'See Attached "ExhibR B" <br />(80 - Water or Mineral rights <br />Enter any additional codes <br />(see bad of last 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)?OYes 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? byes and <br />the transfer axon, multiple parcels with different dasu8cnlom, <br />complete the predominate use calculator (see Instructions) []Yes ONO <br />6 is this property designated as forest land per RCW 84.337 Dyes ONO <br />Is this property classified as current use (open space, farm <br />and agricultural, or timber) land per RCW 84.34? 11 Yes O No <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 Quit Claim Deed <br />Date of document <br />Is this property receiving special valuation as historical <br />Gross selling price <br />0.00 <br />property per RCW 84.26? ❑yesONO <br />*Personal property (deduct) <br />0.00 <br />If any answers are yes, complete as instructed below. <br />(1) NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) <br />Exemption chimed (deduct)0.00 <br />NEW OWNER(S): To continue the current designation as forest land <br />Taxable selling price <br />0.00 <br />or classification as current use (open space, farm and agriculture, or <br />Excise tax: state <br />timber) land, you must sign on (3) below. The county assessor must then <br />determine R the land transferred continues to qualify and will indicate <br />Less than $500,000.01 at 1.1% <br />0.00 <br />by signing below. if the land no longer qualifies or you do not wish to <br />From $500,000.01 to $1,500,000 at 1.28% <br />000 <br />continue the designation or classification, it will be removed and the <br />compensating or additional taxes wi 11 be due and payable by the set ler <br />From $1,500,000.01 to$3,000,ODO at 2.75% <br />0.00 <br />or transferor at the time of sale (RCW 84.33.140 or 84.34.108). Prior to <br />Above$3,000,000 at 3% <br />0.00 <br />signing (3) below, you may contact your [out county assessor for more <br />information. <br />Agri. Mural and timberland at 1.28% <br />0.00 <br />This land: ❑does ❑ does not qualify for <br />Total excise tar. state <br />0.00 <br />continuance. <br />0.0025 Local <br />0.00 <br />Deputy assessor signature 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 owners) 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 />500 <br />(3) NEW OWNER(5) SIGNATURE <br />Affidavit processing fee <br />5.00 <br />Signature Signature <br />Total due 10.00 <br />A MINIMUM OF $10.0015 DUE IN FEE(5) AND/OR TAX <br />Fitt name Prim name <br />*SEE INSTRUCTIONS <br />I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT <br />Signature of g <br />Name (print). <br />Date & city of <br />Signature of, <br />Name (print) <br />Date & city o <br />r=;r•^••1_•_•� �U_ * sa ue iy wnicn is pumsname Dy conrmement in a state correctional institution for a maximum term of fir <br />a fne In an amount xed by the court of not more than $10,000, or by both such confinement and fine (RCW 9A.72.030 and RCW 9A.20.0 <br />To ask about the availability of this publication in an alternate format for the vibually impaired, please call 360-705-6705. <br />(TTY) users may use the WA Relay Service Dy calling 711. <br />REy840001a (5/31/32) THIS SPACE TREASURER'S USE ONLY COUNTY TREASURER <br />Print on legal size paper. <br />Page 1 of 6 <br />