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Re'fffifiE@ Real EState ExCiSe Tax Affid3yi[ 1ncwe24owAc4o8-o14) <br />Ortly fqr sales in a singl€ iocatjon codp nn 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/eoie type or priit. <br />Woshrngton Stdte <br />Form 84 0S01 a <br />El Check box if partial sale, indicate %_ sold. <br />1 seller/G.antor <br />Name Kittitas Countv <br />Aftn: Board of Countu <br />Mailing address 205 W Sth Avenue. Suite 108 <br />City/state/zip Ellensburo WA 98926 <br />Phone (includint area code)509-962-7508 <br />3 Send all property tax correspondence to: Z Same as Buyer/Grantee <br />accurately completed. <br />List percentage of ownership acquired next to each name. <br />2 Buyer/crantee <br />Name Washinoton Slate Denartmenl nf Ecoloov <br />State Trust Water Riohts Prnoram <br />Mailing address 1250 W Alder Shcct <br />city/state/zip Union GaP, WA 98903 <br />Phone (including area code)509-575-24qn <br />List all real and personal property tax <br />parcel account numbers <br />1 94835-$203.000 <br />224835-$140,000 <br />Perconal Assessed <br />value(s) <br />$ 0.00 <br />Name <br />property? <br />Mailing address <br />City/state/zip <br />4 Street address of <br />This property is located in (fer uilincorpor{ted lacations please sele* yow $unty} <br />E 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 />of a sheet to <br />!!n <br />5 - Water or Mineral <br />Enter any additional codes <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)? <br />5 ls this property designated as forest land per RCW 84.337 Dves Elt'lo <br />ls this property classified as current use (open space, farm <br />and agricultural, ortimber) land per RCW84.34? EyesE ruo <br />ls this property receiving special valuation as historical <br />property per RCW84.26? EVesE trto <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 desitnation as forest land <br />or classification as current use (open space, farm and a6riculture, 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 classifica6on, 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 84.34.109). 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 />7 List all personal property (tangible and intangible) included in sellint <br />price. <br />lf claiming an exemption, list WAC number and reason for exemption. <br />E Yes Z ruo wAC number (section/subsection) 458-61 4-205 <br />Reason for exemption <br />Per Article Xl of the Washington State Constitution, the grantor is a <br />EYes Et'to governmental entity. <br />Type of document fJrril Cleim Dped <br />Date of document <br />Gross selling price <br />*Personal property (dedua) <br />Exemption claimed (deduct) <br />Taxable selling price <br />Excise tax: state <br />000 <br />0.00 <br />0.00 <br />000 <br />Less than 5500,000.01 at 1.1% 0.00 <br />From S50O,OO0.O1 to S1,5OO,OOO at 1.28% 0.00 <br />From 51,500,000.01 to 53,000,000 at 2.tSy" 0.00 <br />Above S3,000,000 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 technoloty fee <br />Affidavit processing fee <br />Total due <br />000 <br />0.00 <br />000 <br />000 <br />000 <br />0.00 <br />5.00 <br />'10.00 <br />000 <br />0.00(2) NOflCE OF COMPUANCE (HtSTORtC pROpERTyl <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 />(31 NEW OWNER(S) StGNATURE <br />500 <br />Signature Signature <br />Print name Print nam€ <br />A MTNTMUM OF s10.00 rS DUE tN FEE(SI AND/OR TAX*SEE INSTRUCTIONS <br />GReset form <br />Aftached "ExhibitA" <br />U I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT <br />Signature of grantor or agent _ <br />Name (print) <br />Date & city of signing <br />- <br />Signature of grantee or agent <br />--Name (print)- <br />Date & city of signing <br />- <br />punishable by confinement in <br />than 510,000, or by both such <br />a state correctional institution for a maximum term of five vears. or <br />confinement and fine (RCW 9A.72.030 and RCW 94.20.021(1)(cil. <br />ro ask about the availability of thit ofiq{,i1!"JJ[,1!',j13'il%,i,fs'flittJ3t,li.x'By.Jlijf,fflT3, prease carr36G70567os.reretvpe <br />class C <br />the cou more <br />ts <br />COUNTY TREASURER <br />Print on tegqt size psp*r, <br />REV 84 0001a (s/31l22)THIS SPACE TREASURER'S USE ONLY <br />Page 1 of6