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RB"i'ffil[@ <br />Woshington Stote <br />Form 84 0001 a <br />Real Estate Excise Tax Affidovit tncw <br />Orrly fcr sales in a single location code on or aflef Jtl.t 7,2A72. <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 type or print. <br />82.45 WAC 458-61A) <br />accurately completed. <br />El Check box if partial sale, indicate %- sold. <br />1 seller/Grantor <br />Name Kittites Countu <br />Attn: Board of Corntu <br />Mailing address 205 W Sth Avenue, Suite 1 08 <br />City/state/zip Fllcnqhrrro WA qAq?6 <br />Phone (includins ar"t.66s1 509-962-7508 <br />3 Send all property tax correspondence to: E Same as Buyer/Grantee <br />Name <br />Mailing address <br />City/state/zip <br />4 Street address of <br />This property is located in <br />E Check box if any of the <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 84.36, 84.37, or 84.38 (nonprofit org., senior <br />citizen or disabled person, homeowner with limited income)? D Ves E trto <br />ls this property predominately used for timber (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? ]f yes and <br />the transfer involves multiple parels with different classifi cations, <br />complete the predominate use calculator (ee instructionsl <br />5 ls this property designated as forest land per Rcw 84.337 Eves Etlo <br />ls this property classified as current use (open space, farm <br />and agricultural, or timber) land per RCW 84.34? E Ves Z trto <br />ls this property receiving special valuation as historical <br />property per RCW 84.26? E yes E t',to <br />lf any answers are yes, complete as instructed below. <br />(1) NOTTCE OF CONTTNUANCE (FOREST 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 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 El does not qualify for <br />continuance. <br />Deputy assessor signature Date <br />(2) NOflCE OF COMPLTANCE (HISTORtC pROPERWI <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 84.25, shall be due and payable by the seller <br />or transferor at the time of sale. <br />(31 NEW OwNER(Sl S|GNATURE <br />Signature Signature <br />Print name Print name <br />List percentage of ownership acquired next to each name. <br />2 Buyer/Grantee <br />Name Wachin^t^n Strla nAnrrlmanl ^f Fcoloov <br />Siata Tn rcl Watar Pinhfc Prnnrrm <br />Mailinc address 1250 W Alder Street <br />City/state/zip lJnion Gan WA 98q03 <br />Phone (including area code)509-575-2490 <br />List all real and personal property tax <br />parcel account numbers <br />See Attached "Exhibit A" <br />Personal <br />$ 0.00 <br />$ 0.00 <br />property? <br />Assessed <br />value(s) <br />$ 0.00!n! <br />{for dninearpamted lamtions pletse seled yew &utlty} <br />listed parcels are being segregated from another parcel, are part of a boundary line adjustment or parcels being merged. <br />attach a sheet to <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 />WAC number (section/subsection)458-61 A-205 <br />Reason for exemption <br />Per Article Xl of the Washington State Constitution, the grantor is a <br />Eves ENo governmental entity. <br />Type of document Quit Claim Deed <br />Date of document <br />Gross selling price <br />*Personal propeny (deduct) <br />Exemption claimed (deduct) <br />0.00 <br />0.00 <br />000 <br />Taxable selling pric <br />Excise tax: state <br />Less than S5OO,OO0.or at r.r'Z 0.00 <br />From 5500,000.01 to 51,500,000 at 1.2gX 0.00 <br />From 51,500,000.01 to 53,000,000 at 2.tSy" 0.00 <br />Above $3,000,000 at 3% <br />Agricultural and timberland at 1.28% <br />Total excise tax; state <br />0.0025 Local <br />* Delinquent interest: state <br />Local <br />*Delinquent penalty <br />subtotal <br />*State technology fee <br />Affidavit processing fee <br />Total due <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 />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 />OReset form <br />Aftached "Exhibit B" <br />U I CERTIFY UNDER PENALW oF PERJURY THAT THE FoREGoING Is TRUE AND coRREcT <br />Signature ofgrantor or agent _ <br />Name (print) <br />Date & city of si8ning <br />- <br />Signature of trantee or agent <br />Name (print)- <br />Date & city of signing <br />- <br />Perjury in the second degree is a class C felony which is <br />a fine in an amount fixed by the court of hot 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 94.72.030 and RCW 9A.20.021(1Xc)1. <br />To ask about the availability of this pgq!.itation in an alternate.forln?t fo-r the visually.impairgd, please call 360-7056705. Teletype <br />( I t Y) users may use the WA Relay Service by ciillind 7l I. <br />REV840001a (s/31l22) THTSSPACETREASURER'SUSEONLY COUNTYTREASURER <br />Print o,t legal size poper, <br />Page 1 of 6