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Department of <br />Revenue @ Real EState ExCiSe Tax AffidSyi[ 1ncwa2.4swAc4s8-61A) <br />Woshington State <br />Form 84 00Ol a <br />Only for sales in a single lor:ation code an 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 type or print. <br />accurately completed. <br />El Check box if partial sale, indicate %_ sold. <br />1 SellerTcrntor <br />Name l(iflific a'^r rnh, <br />Ahn Fl^tr.l nfOnrrnhr <br />tvtailing aooress 205 W Sth Avenue, Suite 1 08 <br />City/state/zip Ellensburo, WA 98926 <br />Phone (including area code)509-962-7508 <br />3 Send all property tax correspondence to: E Same as Buyer/Grantee <br />Name <br />5 - Water or Mineral hts <br />Enter any additional codes <br />- <br />(see back of last pate 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 />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? lfyes and <br />tte transfer involves multlple parcels wift different classifications, <br />complete the p.edominate us calculator (see instructions) <br />6 ts this property designated as forest land per Rcw 84.33? flves Elttto <br />ls this property classified as current use (open space, farm <br />and agricultural, or timber) land per RCW 84.34? E Yes E ttio <br />ls this property receiving special valuation as historical <br />property per RCW 84.26? E Yes Z t'lo <br />lf any answers are yes, complete as instructed below <br />(1) NOTTCE OF CONITNUANCE (FOREST LAND 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 />i nfo rm ati on . <br />This land: E does E does not qualify for <br />continuance. <br />Deputy assessor signature Date <br />(2) NOflCE OF COMPLTANCE (HtSTORtC pROpERW) <br />NEW OWNER(S): To continue special valuation as historic property, sign <br />(31 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(S) SIGNATURE <br />Signature Signature <br />Print name Print name <br />List percentaBe of ownership acquired next to each name. <br />2 Buyer/Grantee <br />Name Washinoton State Deoartment of Ecoloov <br />State Trust Water Riqhts Program <br />Mailing address 1250 W Alder Street <br />City/state/zip Union Gap, WA 98903 <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 Assessed <br />value(s) <br />$ 0.00 <br />$ 0.00 <br />property? <br />Mailing address <br />City/state/zip $ 0.00 <br />4 Street address of <br />This property is located in {fer uniftcoryeruted tocutions ptewe s€led yout ttuilty} <br />Check box ifany ofthe listed parcels are being segregated from another parcel, are part of a boundary line adjustment or parcels being merged. <br />need more attach a sheet to each <br />7 List all personal property (tangible and intantible) included in selling <br />price. <br />lf claiming an exemption, list WAC number and reason for exemption. <br />D yes Z t'to wAc number (section/subsection)458-61A-205 <br />Reason for exemption <br />Per Article Xl of the Washington State Constitution, the grantor is a <br />ElYes Etrlo governmental entity' <br />Type of document <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 />Less than 5500,000.01 at I.I% <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />From 5500,000.01 to S1,5oo,ooo at 1.2e"/" 0.00 <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 Local <br />* Delinquent interest: state <br />Local <br />*Delinquent penalty <br />subtotal <br />*State technology fee <br />Affidavit processing fee <br />fotal 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 />000 <br />5.00 <br />5.00 <br />10 00 <br />A MTNTMUM OF s10.00 rS DUE rN FEE(S) AND/OR TAX <br />*SEE INSTRUCTIONS <br />QReset form <br />See Aftached "Exhibit B" <br />8 I CERTIFY UNDER PENALW 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 {orint} <br />- <br />Date & city of signing <br />- <br />a rn an am <br />is a class C felony which is punishable bv confinement in a state correctional institution for <br />by the court of not more than 510,000, or by both such confinement and fine (RCW 9A.72 <br />or <br />Print an legal size paper, <br />Page 1 of 6 <br />To ask about the availability of this publication in an alternate format fqr the visually impairgd, please call 360-7056705. Teletype' (TTY) users may use the WA Relay Service by ciillin$ 71 l. ' <br />REV8aooola (s/31l22) THISSPACETREASURER'SUSEONLY COUNTYTREASURER