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Rail?iffti'l(e <br />Washington Stote <br />Ywrrm &4 WZ&W <br />Levy Certification R/EcErvED c v <br />submit this document, or something simirar, to the *""$qUrf,f,dffi?' f <br />authoritv on or before November 30 of the y".r pr"ffi$Ffip,fiffiqwhich <br />the levy amounts are to be collected. rrr' r'rrro t'uuNrYAssEss0B <br />Courtesy copy may be provided to the county assessor. <br />This form is not designed for the certification of levies under Rcw g4.52.070. <br />ln accordance with RCW 84.52 .O2O, t &1;tnwir,4- LAOarull-- (Nome), <br />Stu*latvq- f-,\1a/ d,J n rT, ffitte),rc, C$laa b 6wProkc,h.,"-,Disf.6 (District name),J <br />do hereby certlfy to the 14 +f, t"a (Name of county)county legislative authority <br />that the ( w'un"'s^iaruAA pommissioners, council, Boord, etc.) ofsaid district requests <br />that the following levy amounts be collected in f,otJ ffeor of collection)as provided in the district,s <br />budget, which was adopted following a public hearing held on tt/a> f eu (Date of public heoring). <br />R ular levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construction leviesExamples of other amounts may include levy error cor rection or adjudicated refund amount. please includea description en using the "r" options <br />Signature Date:L <br />To req <br />or call <br />ues s document in an alternate for mat, p lease complete the form dor.wa.gov/Accessi bi lityReq uest360-705-6705. Teletype (TTy) users p <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />cl I 5, ooo <br />Administrative refund amount lt)41 ,(0L <br />Non-voted bond debt amount 4- <br />Other*4- <br />Levy General levy Other levy* <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />"€- <br />l-.,l <br />Administrative refund <br />amount <br />"+ <br />Other*4- <br />General <br />(n/a for school <br />d istricts) <br />Enrichment <br />(school <br />districts only) <br />OtherBondCap. project <br />*Levy <br />REV 64 OTOO (8/27/2t) <br />lease d ial711 . <br />Page 1 of 1