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Ra;#ffii[(@ <br />Woshingto, stote <br />Form 84 O0O1a <br />Real EState EXCiSe TaX Affidayif lncwez.+swAc4b8-61A) <br />Only for sales in a single location code on oa afler July I,2022. <br />This affidavit will not be accepted unless.all areas on all pages are fully and accurately completed. <br />I nis torm ls your receipt when stamped by cashier pleqse type or print. <br />n Check box if partlal sale, indicate %- sold. <br />1 seller/crantor <br />Name Kttilre nn,,ntu <br />Atln: Boerd nf Cdrntu <br />Mailing address 205 W sth Avenue. Suite 108 <br />City/state/zi p Fllanshrrrd WA qAq?6 <br />Phone (includlng area coOel 509-962'7508 <br />3 5end all propertytax correspondence to:E same as Buyer/Grantee <br />Name <br />Mailing address <br />City/state,/zip <br />- <br />Enter any additional <br />Signature Slgnature <br />Print name Print name <br />I CERTIFY UNDER PENALTY <br />Llst percentage ofownership acqulred next to each name. <br />2 Buyer/crantee <br />p"r" lVashinqton State Deoartment of Ecoloov <br />State Trust Water Riohls Prodrem <br />Mailing adare55 1250 W Alder Street <br />envt<tztat,i^ Union Gao. WA 98903 <br />Phone (including area codel 509-575'2490 <br />List all real and peEonal property tax <br />parcel a.count numbers <br />Assessed <br />value(s) <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />Personal <br />prop€rty? <br />(see back of last page for instructions) <br />Was the seller receiving a propertv tax exemption or deferralunder RCW 84.36,84.37, or84.38 (nonprofiforg., senior <br />citizen or disabled person, homeowner with limited lncome)? Eyes E No <br />6 ts this property deslgnated as forest land per RCW 84.33? EVes Ef',to <br />ls this property classified as current use (open space, farm <br />and agrlcultural, or timber) land per RCW 84.34? Eyes E lto <br />ls this property receiving special valuation as historlcal <br />property per RCW 84.26? E Ves E tto <br />lf any answers are yes, complete as lnstructed below. <br />(1) NOTTCE OF CONnNUANCE (FOREST |-AND OR CURRENT USE) <br />NEW OWNER(S): To continue the current deslgnation as forest land <br />or classlfication as current use {open space, farm and agriculture, or <br />timber) land, you must sitn on (3) below. The county assessor must then <br />determine if the land transferred continues to qualify and will indicate <br />by signing below. lfthe 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 transferor at the time of sale (RCW 84.33.140 or 84.34.108). prior to <br />signlng (3) below, you may contact your local county assessor for more <br />information. <br />This land: E does E does not quallfyfor <br />continuance. <br />Deputy assessor signature Date <br />(2) NOnCE OF COMPt-tANCE (HISTOR|C pROpERTy) <br />NEW OWNER(S): To continue special valuation as historic property, slgn <br />(3) below. lfthe newowner(s) doesn't wish to continue, all addjtional tax <br />calculated pursuant to RCW 84,26, shall be due and payable bythe seller <br />ortransferor at the time ofsale. <br />(3) NEW OwNER{S} STGNATURE <br />Reason for exemption <br />Per Article XI of the Washington State Constitution, the grantor is a <br />Eves 9r'ro govemmental entity. <br />Ptn of 13678-$434.940 <br />7 Llst all personal property {tangible and intangible) included in selling <br />price. <br />lf claiming an exemption, llst WAC number and reason for exemption <br />WAC number l(F.fidn/<"h...fi^nl <br />Type of document Ouit Claim Deed <br />tr <br />tr! <br />4 street address of <br />Ihis property is located (for unincoryotuted locstlons please selectyoqt county) <br />E check box ifany ofthe listed parcels are being segregated from another parcel, are part of a boundary line adjustment or parcels being merged. <br />more to each of <br />5 <br />Date of document <br />Gross selling price 0nn <br />*Personal property (deduct) 0.00 <br />Exemption claimed {deduct) 0.00 <br />Taxable selllng price 0.00 <br />Excise tax: state <br />Less than 5500,000.01 at 1.1%0nn <br />From S5oo,oo0.o1 to S1,s00,ooo at 1.28% 0.00 <br />From S1,500,000.01 to S3,0OO,0OO at 2.7S% <br />Above 53,000,000 at 3% <br />Agricultural and timbetland at !,28% <br />Total excise tax: state <br />0.00 <br />0n0 <br />0n0 <br />0.0020 Local 0.00 <br />*Delinquent interest: state 0.00 <br />nnn <br />0nn <br />0.00 <br />0.00 <br />500 <br />500 <br />10 0n <br />or <br />COUNTYTREASURER <br />Print on legdl size pdp <br />Local <br />'Dellnquent penalty <br />subtotal <br />*State technology fee <br />Affidavlt processing fee <br />Total due <br />A MTNTMUM OF $10.00 ts DUE lN FEE(SI AND/OR TAX*SEE INSTRUCTIONS <br />Signature of <br />Name (print) <br />or agent <br />Date & clty ofslgning B <br />Perjury in the second degce is a <br />a fine in an amount fixed by <br />IS TRUE AND CORRECT <br />or <br />Signature of <br />Name (print) <br />or agent <br />oateacityofstgning ?l2tlzozz I l.wlon &aP, t'tA <br />court not more <br />To ask about the availability of this p(ublicntimin il il::'iitirlff't?iJ"s'"t'[i.X'li'Jli,iry9 "1' orease carr 360'705-670s'reretvpe <br />S€e Attached "Exhibit A <br />- Water or <br />REVsao00la (s/31/22)THIS SPACE TREASURER'S USE ONLY <br />Pase 1 (