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R4"i"6fiil[@ I <br />Woshington Stdte I <br />Form 84O0O1a I <br />Real EState ExCiSe Tax Affidavit (ncwez.+swAc4sB€1A) <br />Only forsales In a single location code on or afte( July 1-,2022. <br />This affidavit will not be accepted unless all areas on all pages are fully and accurately completed. <br />This form is your receipt when stam ped 6y cashie. Pledse type or print. <br />List percentage of owneaship acquired next to each name. <br />2 Euyer/crantee <br />E Check box if partial sale, indicate %- sold. <br />1 seller/crantor <br />Name Kittitas Countv <br />Attn: Board of Countv Commissioners <br />Mailing address 205 W sth Avenue. Suite 108 <br />city/state/zi p Ellensburo. WA 98926 <br />Phone {including area code)509-962-7508 <br />3 Send all property tax correspondence to: E Same as Buyer/Grantee <br />Name <br />Malling eddress- <br />City/state/zip <br />- <br />4 street address of <br />This property is located in <br />E check box if any ofthe <br />5 <br />Enter any addltional codes <br />- <br />(see back of last page for lnstructions) <br />Was the seller receiving a property tax exemption or deferral <br />under RCW 84.36, 84.37, o.84.38 (nonprotit org., senlor <br />citizen or disabled person, homeowner with limited lncome)? <br />ls this property predoninately used fortlmber {asclassified <br />under RCW 84,34and 84,33) oragrlculture {as cla$ified under <br />RCW 84,34.020) and will continue in it's current use? lfyesand <br />the transfer lnvolves multlple pa.cels with dlfferst €la$|ff€dons, <br />@mplete the predominate us alculator (w Instruc{ons) <br />Name Washinoton State Deoartmentof Emloov <br />State Trust Water Riohts Proqram <br />Mailing address 1250 W Alder Street <br />City/state/zlp Union Gap. WA 98903 <br />Phone (including area code)509-575-2490 <br />Personal Assessed <br />value(s) <br />$ 0.00 <br />13497-$579,670 <br />$ 0.00 <br />(lot unincorpordted locdtions pledse selectyour county) <br />number and reason for exemption. <br />458.61A-205 <br />Reason for exemption <br />Per Article Xl of the Washington State Constitution, lhe grantor is a <br />Eyes Vl No govemmental entity. <br />Type of r^-,-..o Quit Claim Deed <br />Eves E ttto Date of document <br />- <br />Gross selling price <br />tPersonal property (deduct) <br />Exemption claimed (deduct) <br />Taxable selling price <br />Excise tax: state <br />Less than S500,000.01 at 1.1% <br />000 <br />000 <br />000 <br />000 <br />000 <br />From S5Oo,0OO.01 to 51,500,000 at 1.28% 0.00 <br />From s1,500,000.01 to s3,000,000 at 2.75%000 <br />lf claiming an exemption, list WAC <br />E ves E lto WAc number (section/subsection) <br />Llst all real and peFonal property tax <br />parcel account numbers <br />13495-$205.400 <br />property? <br />$ 0.00 <br />n <br />n <br />tr <br />parcel, are part of a boundary llne adjustment or parcels being merged. <br />of <br />30 - Water or Mineral riqhts 7 List all personal property (tangible and intanglble) included in selling <br />price. <br />6 ts this property designated as forest land per RcW 84.33? Elves Elt'to <br />ls this property classified as current use (open space, farm <br />and agricultural, or timber) land per RCW 84,34? <br />ls this property recelvlng special valuation as historlcal <br />property per RCW 84.26? EvesE wo <br />lfany answers are yes, complete as instructed below. <br />(1) NOTTCE OF CONnNUANCE (FOREST |.AND OR CURRENT USE) <br />NEW OWNER(S): To continue the current designation as forest land <br />or classification as current use (open space, fdrm and agriculture, or <br />timber) land, you must slgn on {3) below, The county assessor must then <br />determlne ifthe land ftansferred con6nues to qualify and will indicate <br />by signing belou lf the land no longer quallfies or you do not wish to <br />continue the deslgnation or classification, it will be removed and the <br />compensatingoradditionaltaxes will be due and payable bythe seller <br />or transferor at the time of sale (RCW 84.33.140 or 84,34.108), Prior to <br />slgning (3) below, you may contact your local county assessor for more <br />information. <br />This land: E does E does not qualifyfor <br />continuance. <br />Deputy assessor signature Date <br />(2) NOnCE OF COMPUANCE (HTSTORTC PROPERTYI <br />NEW OWNER(S): To continue special valuation as historic property, sign <br />(3) below. Ifthe 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 atthe time ofsale. <br />(3) NEW OWNER(S) STGNATURE <br />Signature Signature <br />Print name <br />I CERTIFY UNDER PENAI-TY <br />Above 53,000,000 at 3% <br />Agricu ltura I a n d tim be iland at 7.280/" <br />Total excise tax: state <br />0.0025 Local <br />*Delinquent interest: state <br />Local <br />tDelinquent penalty <br />Subtotal <br />*state technology fee <br />Affidavit proces5ing fee <br />Total due <br />A MTNTMUM OF s10.00 rS DUE rN FEE(S) AND/OR TAX <br />*SEE INSTRUCTIONS <br />0.00 <br />000 <br />000 <br />000 <br />000 <br />nn0 <br />0.00 <br />0.00 <br />5.00 <br />5.00 <br />10 00 <br />IS TRUE AND CORRECT <br />Signature of <br />Name (prlnt) <br />Date & clty of slgnlng <br />Slgnature ofgrantee or agent <br />Name (print) <br />oate&cityofsigntng ?128/22 VLtiot G-P, Wl <br />tn <br />in an amount by the court of not or by both such 9A. <br />To ask about the availability of this publication in an alternate format for the visuallv impaired, please call 360-705-6705. Teletype' (TTY) users mayusetheWA RelayService byciillingj 7I 1.' <br />REvs4ooola (5/31/22) THISSPACETREASURER'SUSEONLY COUNTYTREASURER <br />Print on legol size pope <br />lsa c ls or b\ <br />Attached "Exhibit A" <br />Page 1 o