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nlTtililit@ <br />Woshington Stote <br />Forrn 54 CI100 <br />Levy Certification <br />Submit this document, or something similaq to the county tegislative <br />authority on or before November 3O of the year preceding tli" y"rr in which <br />the levy amounts are to be collected. <br />Courtesy copy may be provided to the county assessor. <br />This forrn is not designed for the certification of levies under RCW 84.52.070. <br />ln accordance with Rcw 84.s2.020, I At-/UfL C"J"J.S (Name), <br />Sqlrr"h-v ffitte),ro, k-&4*r Cd,r*4:Filz */ (District nome), <br />do hereby.*rti/y to the (Ca"l^*ri61*,q,.$ ki+6{n{ (Name of ,(unty)county tegistative authority <br />.. a <br />that the C.cmfy$581t r\r/fJ (Commissioners, Council, Board, etc.) of said district requests <br />that the following levy amounts be collected in ?bA ffeor of colectionl as provided in the district's <br />budget, which was adopted following a public hearing held on /r/Ay'U @ate of public hearing). <br />lar levies <br />Excess levies <br />Examples of other levy types may include EMS, school district transportation, or construction evies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. Please include <br />a description when usi <br />Signature:riafe: ll-30 -ea* <br />To request this docu <br />or cal|360.705,67A5 <br />please complete the forrn dor.wa.g ov/AcFess ibi lityReqqest <br />1 <br />Total certified levy request <br />amount which includes the <br />amounts below.?177 ? L <br />Admin istrative refund amount <br />Non-voted bond debt amount <br />Other* <br />Levy General levy Other levy* <br />Totalcertified levy <br />request amount, <br />which includes the <br />amounts below. <br />Administrative refund <br />amount <br />Other* <br />General <br />(n/a for school <br />districts) <br />Enrichment <br />{sc hool <br />districts only) <br />Other levy*ruLevyBondCap. project <br />REV 64 OLOO ls/27l2tl <br />"other" <br />dial71 <br />Page 1 of 1