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Ra{,ffilit@ <br />Woshington Stote <br />Fonrn 64 0n00 <br />Levy Certification <br />Submit this document, or something similar, to the county legislative <br />authority on or before November 30 of the year preceding the year in which <br />the levy amounts are to be collected. <br />Courtesy copy may be provided to the county assessor. <br />This form is not designed for the certification of levies under RCW 84.52.070. <br />ln accordance with RCW 94.52.020, I DaleScottOlander (Name), <br />Treasurer Fitle),1o, Kittitas county Public Hospital District No. 2 pistrict name), <br />do hereby certify to the Kittitas (Nome of county)County legislative authority <br />that the Board of commissioners Qommissioners, council, Board, etc.)of said district requests <br />that the following levy amounts be colleclg6 ;n 2023 (Year of collection) as provided in the district's <br />budget, which was adopted following a public hearing held on LL'21-2o22 (Dote of pubtic heoring). <br />ular levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construction levies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. please include <br />a description when usin the "ot r" options <br />nature: t Date: tt I zz-/z.o'e?---sig <br />I' <br />To requg$ this document in an alternate format, please complete the form dor.wa.gov/AccessibilityRequest <br />or call 360-705-6705. Teletype (TTY) users please dial 71 1. <br />REV64o1o0 (8l27l2Ll pagelofl <br />EMS <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ 2,ooo,ooo.oo $ z,ooo,ooo.oo <br />Administrative refund amount <br />Non-voted bond. debt amount <br />Other* <br />General levy Other levy*Levy <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />L--.,l <br />Administrative refund <br />amount <br />Other* <br />General <br />(n/a for school <br />d istricts ) <br />Enrichment <br />{school <br />districts only) <br />Other I <br />Bond Cap. projectLevy