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Ra"itfiil[(@ <br />Woshington 5tote <br />Form 84 0001a <br />EI Check box if partial sale, indicate %- sold. <br />1 Seller/Grantor <br />Name Kittitas County <br />Aftn Pnarrl nfOnrrnhr <br />Real EState ExCiSe Tax AffidSyi[ lncwa24swAc4sB-61A) <br />Only for sales in a single location code on or after luly 1, 2022. <br />This affidavit wlll not be accepted unless all areas on all pages are fully and accurately completed. <br />This form is your receipt when stamped by cashier, P/eose type or print. <br />List percentage of ownership acquired next to each name. <br />2 auyer/Grantee <br />\A/.chi^^r^n Qr.l6 nan.dm6nt ^f FnnloovName <br />State Trust Water Riqhts Prooram <br />Mailing address 205 W Sth Avenue. Suite 1 08 <br />Mailing address 1250 W Alder Skeet <br />city/state/zip Ellensburo. WA 98926 <br />City/state/zip Union GaD. WA 98903 <br />509-962-7508Phone (including area code) <br />3 Send all property tax correspondence to: E Same as Buyer/Grantee <br />Name <br />Mailing address <br />City/state/zip <br />5 ls this property desitnated as forest land per RcW 84.332 EYes Etto <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 receiving special valuation as historical <br />property per RCW 84.25? E Ves E trto <br />lf any answers are yes, complete as instructed below. <br />(1) NOTTCE OF CONTTNUANCE (FOREST tAND OR CURRENT USE) <br />NEW OWNER(5): 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 si8n 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 designation or classlfication, 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 />i nfo rm ati on . <br />This land: E does E does not qualify for <br />continuance. <br />Deputy assessor signature Date <br />(2) NOTTCE OF COMPLTANCE (HrsTORrC PROpERTy) <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(SI STGNATURE <br />Signature Signature <br />Print name Print name <br />Phone (including area code)509-575-2490 <br />List all real and personal property tax <br />parcel account numbers <br />See Aftached "Exhibit A" <br />Personal <br />property? <br />!n! <br />Assessed <br />value(s) <br />$ 0.00 <br />$ 0.00 <br />s 0.00 <br />4 Street address of <br />This property is located in {f*r unincarltarcted laffitions pleLse sele* {au/ ffi$nty} <br />Check box if any of the listed parcels are being segregated from another parcel, are part of a boundary line adjustment or parcels being merged. <br />attach a sheet to each of the <br />5 30 - Water or Mineral rights 7 List all personal property (tangible and intangible) included in selling <br />price. <br />Enter any additional codes <br />- <br />(see back of last page for instructions) <br />Was the seller receiving a property tax exemption or deferral <br />under RCW 84.36, 84.37, ot 84.38 (nonprofit org., senior lf claiming an exemption, list WAC number and reason for exemption. <br />citizen or disabled person, homeowner with limited income)? E Yes Z ruo WAC number (section/subsection) 458-61A-20S <br />ls this prcpertylredominately used for timber (as classified Reason for exemption <br />under RcW 84.34 and 84.33) or agriculture (as classified under <br />Rcw 84.34.020) and will continue in it's current use? lf yes and Per Article Xl of the Washington State Constitution, the grantor is a <br />$i'1ilffi#1ff#j1fl,'"31i:fi[T(g[;rentdqssn'cition' Eyes zrrro sovernmentalentitv. <br />Type of document Quit Claim Deed <br />EYesEl ruo Date ofdocument <br />Gross selling price <br />*Personal propeny (deduct) <br />Exemption claimed (deduct) <br />Taxable selling price <br />Excise tax: state <br />Less than S500,000.01" at L.I% <br />From S500,000.01 to S1,500,000 at 1.28% <br />From S1,500,000.01 to 53,000,000 at 2.75% <br />Above 53,000,000 at 3% <br />Agricultural and timberland at 1.28% <br />Total excise tax: state <br />0.0025 Locat <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />*Delinquent interest: state ---------------- <br />Local <br />*Delinquent penalty <br />Subtotal <br />*state technology fee <br />Affidavit processing fee <br />0.00 <br />0.00 <br />5.00 <br />5.00 <br />Totat due 10.00 <br />A MTNTMUM OF 510.00 rS DUE rN FEE(SI AND/OR TAX <br />*SEE INSTRUCTIONS <br />0.00 <br />0.00 <br />ilReset form <br />Attached "Exhibit B" <br />I CERTIFY UNDER PENATTY OF PERJURY THAT THE FOREGOING I5 TRUE AND CORRECT <br />Signature of grantor or agent <br />Name lDrintl <br />Date & citv of sienins <br />- <br />Sitnature 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 punishable by confinement in a state correctional institution for a maximum term of five years, or by <br />a fine in an amount fixed by the court of not more than 510,000, 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 format for the visually impaired, please call 360-705-6705. Teletype(TfY) users may use the WA Relay Service by c;illind 7l l. ' ' <br />REvs4ooola {s/31/22) THISSPACETREASURER'SUSEONLY COUNTYTREASURER <br />Pvint 0n legal size paper, <br />Page 1 of 6