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<br />Wdshington Stote
<br />Form 84 0001a
<br />Real EState EXCiSe l'laX Affidayil lncwoz.rswAc4bs_61A)
<br />a single location code on or after July 1,
<br />not be accepted unless all areas on all
<br />2022.
<br />pages are
<br />receipt when stampedby cashier. please type or
<br />fully and accurately completed.
<br />print,
<br />E Check box if partialsale, lndicate %_ sold.
<br />1 seller/crantor
<br />List percentage ofownership acquired next to each name.
<br />2 Euyer/Grantee
<br />Name Kittitas Countv
<br />Name Washinqton State Deoarlment of EcoloovAttn: Board of Countv Commissioners State Trust Water Riohls Prooram
<br />vaiting address 205 W 5th Avenue. Suite 108 M:irin, .dd.a(. '1250 W Alder Street.it' J date t ai ^ Ellensburo. WA 98926
<br />City/state/zip
<br />Phone (includlng area code)509.962.7508
<br />Phone (lncluding area coael 509'575-2490
<br />3 Send all property tax correspondence to: E Same as Buyer/crantee List all real and peEonal propertytax personal Asressed
<br />parcel account numbers property? value(s)
<br />Only for sales in
<br />This aftidavit will
<br />This form is your
<br />Name-
<br />960277.$'100 $ 0.00
<br />$ 0,00
<br />Mailing address
<br />-
<br />City/state/zi p
<br />$ 0.00
<br />4 street address of
<br />This property is located in
<br />E Check box if any of the
<br />5
<br />Enter any additional codes
<br />{see back of last page for instructions)
<br />Was the seller receiving a property tax exemotion or deferralunder RCW 84,36, 84.37, or 84.38 (nonprofit org., senior
<br />citizen or disabled person, homeowner with limlted income)?
<br />(!ot unincoryoroted locdtions please selectyour county)
<br />listed parcels are being segregated from another parcel, are part of a boundary line adjustment or parcels being merged.
<br />attach :ofthe
<br />7 List all personal property (tangible and intangible) included tn selling
<br />price.
<br />exemption, list WAC numberand reason for exemption.
<br />(section/subsection) 458-61A"205
<br />Reason for exemption
<br />Per Article Xl of the Washington State Constitution, the grantor is a
<br />govemmental entity.Eves Elro
<br />6 ls this property designated as forest land per RCw 84.33? fhes Et'to
<br />ls this property classified as current use (open space, farm
<br />and agricultural, or timber) land per RCW 84,34? E yes Z No
<br />ls thls property receiving special valuation as hjstorical
<br />property per RCW 84,26? E Ves E t'to
<br />lf any answers are yes, complete as instructed below.
<br />(1) NOnCE OF CONnNUANCE (FORESTT AND OR CURRENT USE)
<br />NEW OWNER(S): To continue the current designation as forest land
<br />or classification as current use (open space, h.m and agriculture, or
<br />timber) land, you must slgn on (3) below. The county assessor must then
<br />determine ifthe land transfurred continues to qualify and will indicate
<br />by signing below lfthe land no longer quallfies oryou do notwish 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 />signing (3) below, you may contact your local county assessor for more
<br />information,
<br />This land: E does E does not qualify for
<br />continuance,
<br />Deputy assessor signature Date
<br />lf claiming an
<br />E Yes E t'to wAc number
<br />Type of document Ouil Claim Deed
<br />Date of docu
<br />Gross selling price
<br />*Personal property (deduct)
<br />Exemption clalmed (deduct)
<br />Taxable selling price
<br />Excise tax: state
<br />00n
<br />0.00
<br />00n
<br />(2) NOnCE OF COMpt-tANCE (H|STOR|C pROpERTy)
<br />NEW OWNER(S):To continue special valuation as historjc property, sign
<br />(3) below. lf the new owner(s) doesn,t wish to continue, all additionai tax
<br />calculated pursuant to RCW 84.26, shall be due and payable by the seller
<br />or transfero. atthe time of sale,
<br />(3) NEW OWNER(S) STGNATURE
<br />000
<br />Less than S500,000.01 at 1.1% 0,00
<br />From s500,000.01 to s1,500,000 at 1.28% 0.00
<br />From s1,500,000.01 to s3,000,000 at 2.75% 0,00
<br />Above S3,000,000 at 3%
<br />Agricu ltu ra I a n d ti m be iland at I.2B%
<br />Total excise tax: state
<br />0.0025 Local
<br />*Delinquent interest: state
<br />Local
<br />*Delinquent penalty
<br />000
<br />0.00
<br />000
<br />000
<br />000
<br />00n
<br />0.00
<br />subtotal 0 00
<br />*state technology fee 5.00
<br />Affidavit processing fee
<br />Total due
<br />500
<br />10 00
<br />A MINIMUM OF SIO.OO IS DUE IN FEE(S} AND/OR TAX*SEE INSTRUCTIONS
<br />IS TRUE AND CORRECT
<br />Signature Signature
<br />Print name
<br />I CERTIFY UNDER PENAI.W OF
<br />Signature of
<br />Name (print)
<br />Date & city of signing
<br />rn an
<br />Print name
<br />court mote
<br />cl,{" *,.h*' q,*
<br />'rlbate &cityof signin g 1 I z?l zozz |!/.qio^ 6o"e, da
<br />c oror by
<br />To ask about the availability of
<br />'n'' ori$iTilTli'11,"J::'iiTi'if;'fl?iJ"sllli.li'ufJyriff?.ii3'prease carr36G705-6Tos reretvpe
<br />COUNTY TREASURER
<br />Attached "ExhibitA"
<br />- Water or
<br />REv84oooTa ls/31/z2l THIS SPACE TREASURER'S USE ONtY
<br />Print on legol size pap,
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