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Department of <br />Revenue @ Real Estate Excise Tax Affidavit tncw <br />Only for sales in a single location code on or after July 1, 2022. <br />This affidavit will not be accepted unless all areas on all pages are fully and <br />This form is your receipt when stamped by cashier. P/eose iype or priit. <br />82.45 WAC 458-61A) <br />accurately completed.Wdshington 5tote <br />Fonnr 84 00Ot a <br />Name <br />Mailing address <br />City/state/zip <br />4 Street address of <br />This property is located in {f*r unitrcarpar$ted totd66nr ple\se selp.t yaw wunty} <br />Check box if any of the listed parcels are being segregated from another parcel, are part of a boundary line adjustment or parcels being merged. <br />need more attach a <br />E Check box if partial sale, indicate%_ sold <br />1 Seller/crantor <br />Name Kiflilec Cnrrntu <br />Attn Flnard ^f CArhtu <br />Mailing address 205 W 5th Avenre SuitA <br />City/state/zip Fllenshrrrn WA q8q2A <br />Phone (including area code)50q-q62-750A <br />3 Send all property tax correspondence to: E Same as Buyer/Grantee <br />5 - Water or Mineral <br />Enter any additional codes <br />- <br />{see back of last page for instructions) <br />Was the seller receiving a property tax exemption or deferral <br />under RCW 84.35,84.37, or 84.38 (nonprofit org., senior <br />citizen or disabled person, homeowner with limited income)? <br />ls this property predominately used fortimber (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? lfyes and <br />the transfer involves multiple parcels with different classiflcations, <br />@mplete the p.edominate us clculator (*e instructions) <br />6 ls this property designated as forest land per RcW 84.337 Elves Et'to <br />ls this property classified as current use (open space, farm <br />and agricultural, ortimber) land per RCW84.34? EyesE trto <br />ls this property receiving special valuation as historical <br />property per RCW 84.26? E Ves E t',to <br />lf any answers are yes, complete as instructed below. <br />(1) NOTTCE OF CONTTNUANCE (FORESI tAND OR CURRENT USE) <br />NEW OWNER(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 must then <br />determine if the land transferred continues to qualify and will indicate <br />by signing below. lf the land no longer qualifies or you do not wish to <br />continue the desiBnation 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 8 4.33.!40 ot 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 D does not qualify for <br />continuance. <br />Deputy assessor signature Date <br />(2) NOTTCE OF COMPLTANCE (HtSTORtC pROpERw) <br />NEW OWNER(S): To continue special valuation as historic property, sign <br />(3) below. lf 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(Sl StGNATURE <br />Signature Signature <br />Print name Print name <br />List percentage of ownership acquired next to each name. <br />2 auyer/Grantee <br />Name Waqhinntnn Strfa na^arlmanl ^f Fcoloov <br />Slatp Tnrct Welpr Rinhlc Prnnrem <br />Mailing address 1 950 lAl Aldor Qtraaf <br />City/state/zip I lninn Gen lAlA OAOn? <br />Phone (including area codel 509:575-2490 <br />List all real and personal property tax <br />parcel account numbers <br />951 892-$745.1 30 <br />845034-$1 96,1 50 <br />951 893-$73.000 <br />Personal <br />property? <br />!!I <br />Assessed <br />value{s} <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />7 List all personal property (tangible and intangible) included in selling <br />price. <br />lf claiming an exemption, list WAC number and reason for exemption. <br />EvesE t'to wAC number (section/subsection) 458-614-205 <br />Reason for exemption <br />Per Article Xl of the Washington State Constitution, the grantor is a <br />EYes Ztto governmental entity' <br />Type of document Quit Claim Deed <br />Date of document <br />Gross selling price <br />*Personal property (deduct) <br />Exemption claimed {deduct) <br />Taxable selling price <br />Excise tax: state <br />0.00 <br />0.00 <br />000 <br />0.00 <br />Less than 5500,000.0r at r.roz 0 00 <br />From S5OO,O00.O1 to 51,500,000 at l-.24./. 0.00 <br />From 51,500,000.01 to 53,000,000 at 2 .tSy" 0.00 <br />Above 53,000,000 a1 37" 0.00 <br />Agricultural and timberland at 1.237" 0.00 <br />Total excise tax: stals 0.00 <br />0.0025 Local 0 00 <br />* Delinquent interest: state <br />Local <br />*Delinquent penalty <br />Subtotal <br />*State technology fee <br />Affidavit processint fee <br />Total due <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />5.00 <br />5.00 <br />10.00 <br />A MTNTMUM OF s10.00 tS DUE tN FEE(S) AND/OR TAX*SEE INSTRUCTIONS <br />ilReset form <br />Attached "Exhibit A" <br />E I CERTIFY UNDER PENATW OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT <br />Signature of grantor or agent _ <br />Name (print) <br />Date & city of signinB <br />- <br />Signature of grantee or agent <br />--Name (print) <br />- <br />Date & city ofsigning <br />- <br />Perjury..in the second degree.is a class C felony which is <br />a trne rn an amount tixed by the court ot not more <br />punishable by confinement in a state correctional institution for a maximum term of five vears. or bv <br />than S10,000; or by both such confinement and fine (RCW 9A.72.030 and RCW 94.20.021(1)(c)1. <br />To ask about the availability of this publication in an alternate format fqr the visually imoqirgd, please call 36G7056705. Teletype' CI-TY) users may use the wA Reiay Seinice by ca{ttirif 7iI:' - ---- <br />REv8aoooLa (s/37/22t. THISSPACETREASURER'S USEONLY COUNTYTREASURER <br />Flint as legat si?.e psper, <br />Page 1 of 6