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Department of Real Estate Excise Tax Affidavit (RCW 82.45 WAC 456-61A) Revenue C Only for sales im a single bcatlon code cn or afterJuly 1, 2022. Washington State 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. 0 Check box if partial sale, indicate% sold. List percentage of ownership acquired nest to each name. 1 seller/Grantor Name Kiditas CouO Attn: Board of County Commissioners Mailing address 205 W 5th Avenue, Suite 108 City/state/zip Ellensburg, WA 98926 Phone (including area code) 509-962-7508 3 Send all property tax correspondence to:0 Same as Buyer/Grantee Name Mailing addrt City/nate/zip 4 Street address of prop, This property is located it ❑ Check box if any of the 2 Buyer/Grantee Name Washington State Department of Ecol State Trust Water Rights Program 0.00 "Personal property (deduct) Mailing address 1250 W Alder Street Exemption claimed )deduct) 0.00 City/nate/zip Union Gag, WA 98903 Ho Excise tax: state Phone (including area code) 509-575-2490 'State technology fee 5.00 List all real and personal property tax personal Assessed parcel account numbers property? value(s) See Attached "Exhibit A" ❑ $ 0,00 ❑ $ 0.00 ❑ $ 0.00 I(for unincorporated locallonspleas,select your county) segregated from another parcel, are part of a boundary line adjustment or parcels being merged Legal description of PrODenv (if you need mores ace, attach a separate sheet to each page of the affidavit). See Attached "Exhibit B" X80 - Water or Mineral rights 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 for timber las classified under RCW 84.34 and 84.33) or agriculture las classified under RCW 84.34.020) and will continue in it's current use? Ryes and the transfer involves multiple parcels with different classifications, complete the predominate use calculator (See instructions) Dyes ONO 6 is this property designated as forest land per RCW 84.337 QYes ONO Is this property classified as current use lopen space, fans and agricultural, or timber) land per RCW 84.347 ❑ Yes No Is this property receiving special valuation as historical property per RCW 84.267 ❑ yes 0 No If any answers are yes, complete as instructed below. (1) NOTICE OF CONTINUANCE (FOREST IAND OR CURRENT USE) NEW OWN ER(S): To continue the current designation as forest land or classification as current use (open space, farm and agriculture, or timber) land, you must sign an (3) below. The county assessor must then determine R the land transferred continues to qualify and will indicate 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 compensating or additional taxes will be due and payable by the seller 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 coumy assessor for more information. This land: ❑does ❑ does not quality for continuance. Deputy assessor signature Date (2) NOTICE OF COMPLIANCE (HISTORIC PROPERTY) NEW OW NER(S): To continue special valuation as historic property, sign (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 or transferor at the time of sale. (3) NEW OWNER(S) SIGNATURE signature Signature Print name Pratt name 7 List all personal property (tangible and intangible) included in selling price. If claiming an exemption, list WAC number and reason for exemption. WAC number (section/subsection) 458-61A-205 Reason for exemption Per Article XI of the Washington State Constitution, the grantor is a governmental entity. Type of document Quit Claim Deed Date of document Gross selling price 0.00 "Personal property (deduct) 0.00 Exemption claimed )deduct) 0.00 Taxable selling price Ho Excise tax: state 0.00 Less than$500,D00.01 at 1.1% 0.00 From $500,000.01 to $1,500,000 at 1.28% 0.00 From $1,500,000.01 to$3,000,OOO at 2.75% 0.00 Above $3,000,000 at 3% 0.00 Agricultural and timberland at 1.28% 0.00 Total excise tax: state 0.00 0.0025 Local 0.00 'Delinquent interest: state 0.00 Local 0.00 'Delinquent penalty 0.00 Subtotal 0.00 'State technology fee 5.00 Affidavit processing fee 5.00 Total due 10.00 A MINIMUM OF $10.0015 DUE IN FEEI51 AND/OR TAX "SEE INSTRUCTIONS I CERTIFY UNDER PENALTY OF PERIURY THAT THE FOREGOING 15 TRUE AND CORRECT Signature of grantor or agent Signature of grantee or Name (PrinU Namp lnriml Date &city of signing Date & city of signing Perjury in the second degnee is a class C felony which is punishable by confinement in a state correctional institution for a maximum term of five( 11 is by a in 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.20.0211 c To askabout the availability of this publication in an alternate format for the visually impaired, please oil 360-705-6705. Teletype (TTy) users may use the WA Relay Service by calling 711. REV840001a (5/31/22) THIS SPACE TREASURER'S USE ONLY COUNTY TREASURER Print on legal size paper. Page 1 of 6