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Ra"fifftit@ Woshington State Form 64. 0nS0 LevyCertification upoo.t*{. submit this document, or something similar, to the county legislative authority on or before November 30 of the year preceding the year in whichthe levy amounts are to be coltected. Courtesy copy may be provided to the county assessor. This form is not designed for the certification of levies under Rcw g4.52.070. ln accordance with Rcw 94.52.020, I Dale scott olande, (wame), chief Financial officer and Treasurer ffitre), for Kittitas county public Hospitat District No. 1 pistrict name), do hereby certify to the Kittitas (Name of county)county legislative authority that the Board of commissioners $ommissioners, Council, Boord, etc.) afsaid district requests that the following levy amounts be collec1"6 ;p 2023 ffear of cailection)as provided in the district,s budget, which was adopted following a public hearing held on Lol27l2a22 (Date of pubtic hearing). lar levies Excess levies *Examples of other Examples of other a a description when levy types may include EMS, school dist rict transportation, or const ruction levies mounts may include levy error correction or adjudicated refund amount. please includeusing the "other" o ptions Signature:Date:L Total certified levy request amount, which includes the amounts below. s 25,000.00 Administrative refund amount $ o.zo Non-voted bond debt amount Other* Levy General levy Other levy* Total certified levy request amount, which includes the amounts below. S so.oo Administrative refund amount s s8.22 Other* General (n/a tor school districts) Enrichment (school districts only) Other levv*rLevyBondCap. project To request this document in an alternate format, p.legle complete the form dor.wa.govlAccessibilityRequestor call 360-70s-6705. Tetetype (TTy) users ptea!; bi;itl i. REV 64 a]!o $/2712!) page 1 of 1