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Department of Real Estate Excise Tax Affidavit (RCW 82.45 WAC 458-61A) <br />Revenue C Only for sales in a singie locitior rode on or after lily 1, 2022. <br />Washrgtan State This affidavit will not be accepted unless all areas on all pages are fully and accurately completed. <br />Form 84 0001 a This farm is your receiptwhen stamped by cashier. Please type orprint. <br />List percentage ownership acquired near to each name. <br />❑Check box if partial sale, indicate % sold. P g P q <br />1 Seller/Grantor <br />Name IUttitas County <br />A8m 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:0 Same as Buyer/Grantee <br />Name <br />Mailing address <br />City/state/zip <br />This property is locxtf <br />[]Check box if. ny of <br />2 Buyer/Grantee <br />Name Washington State Department of Ecoloav <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 />960277-$100 ❑ $0.00 <br />❑ $ 0.00 <br />❑ $ 0.00 <br />(for unincorporated locationsplease select your county) <br />)that 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 />0 - 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, 84.37, or 84.38 (nonprofit org., senior <br />citizen or disabled person, homeowner with limited income)?[]Yes O 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 invokes multiple parcels with different classifications, <br />complete the predominate use calculator hare irutrucdom) []Yes ONO <br />6 Is this property designated as forest land per RCW 84.33? Ores 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 84.267 [] Yes O 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 mug 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 translator at 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: 11 does ❑ does not qualify for <br />continuance. <br />Deputy assessor signature Date <br />(2) NOTICE OF COMPLIANCE (HISTORIC PROPERTY) <br />NEW OWNERS): To continue special valuation as historic property, sign <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 />or transferor at the time of sale. <br />(3) NEW OWNER(S) SIGNATURE <br />Signature <br />Signature <br />Print name Print name <br />O 1 CERTIFY UNDER PENALTY OF PERIURY THAT THE FOREGOING IS TRU <br />Signature of grantor or agent <br />Name (print) <br />Date & city of signing <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 />Gross selling price 0.00 <br />'Personal property (deduct) 0.00 <br />Exemption claimed (deduct) <br />Taxable selling price <br />Excise tax: state <br />Less than $500,000.01 at 1.1% <br />From $500,000.01 to $1,500,000 at 1.28% <br />From $1,500,000.01 to $3,000,000 at 2.7596 <br />0.00 <br />Above $3,000,000 at 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 />0.00 <br />'Delinquent interest: state <br />0.00 <br />'Delinquent penalty <br />O.Uu <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 FEES) AND/OR TAX <br />'SEE INSTRUCTIONS <br />AND CORRECT <br />Signature of grantee or agent <br />Name (print) <br />Date & city of signing <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 formatfor the visually impaired, please call 360-705-6705.Teletype <br />(TTY) users may use the WA Relay Service by calling 711. <br />REV 84 gook (5/31/22) THIS SPACE TREASURER'S USE ONLY COUNTY TREASURER <br />Print on legal size paper. <br />Page 1 of 6 <br />