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Ra"fiffli.fe <br />Woshingron Stote <br />Fonsm 64 01CI0 <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 />rt'options. <br />ln accordance with RCW 94.52.020, I Dale Scott Olander fiome),Treasurer ffitte),;ot. Kittitas county Public Hospitat District No. 2 @istrict name), <br />do hereby certify to the Kittitas (Nome of caunty)County legislative authority <br />that the Board of commissioners Pommissioners, counci!, Board, etc.) of said district requests <br />that the following levy amounts be collesls6 in 2023 ffear of collection)as provided in the district's <br />budget, which was adopted following a public hearing held on tL-2L-2a22 (Date of pubtic hearing). <br />lar levies <br />Excess levies <br />*Examples of other levy types may includ e 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 <br />sig nature: I Date: <br />To request this document in an alternate format, p_lease complete the form dor.wa.govlAccessibilityRequest <br />or call 360-705-6705. Teletype (TTY) users please dial Zt 1 . <br />REV 64 oLAl $l27l2Ll page 1 of 1 <br />EMS <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ 2,ooo,ooo.oo $ 2,0oo,ooo.00 <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-J <br />Administrative refund <br />amount <br />Other* <br />General <br />(n/a far school <br />districts) <br />Enrichrnent <br />{school <br />districts only) <br />Bond Cap. project <br />OtherLevy