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Reitfftit@ <br />Woshington Stote <br />FCIrrn S4.S30G <br />Levy Certification r./ p d,.t*{- <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 g4.52.070. <br />ln accordance with RCW 84.52.020, I DaleScottOtande, (Name), <br />chief Financial officer and rreasurer ffitle),;ot. Kittitas county Puhlic Hospitat District No. t pistrict nome), <br />do hereby certify to the Kittitas (Name of county)county legislative authority <br />that the Board of commissioners (commissioners, council, Boord, etc.) af said district requests <br />that the following levy amounts be collec1"6 1n 2023 (ear of cotlection) as provided in the district,s <br />budget, which was adopted following a public hearing held on 1012712022 (Date af publp hearing). <br />lar levies <br />Excess levies <br />*Examples of other levy types may include EMS, school d istrict tra nspo rtation, or construcfi on I evies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. please include <br />a description when using the "other,, options. <br />Signature:Date:e<_ <br />Total certified levy request <br />amount, which includes the <br />amounts below <br />S zs,ooo.oo <br />Administrative refund amount $ o.zo <br />Non-voted bond debt amount <br />Other* <br />General levy Other levy*Ievy <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />S eo.oo <br />l- <br />Administrative refund <br />amount $ s8.22 <br />Other* <br />General <br />(n/a for school <br />d istricts ) <br />Enrichment <br />(school <br />districts only) <br />Levy Bond Cap. project Other <br />To reques-t this document in an alternate format, p.le91e complete the form dor.wa.gov/Accessibilit)rRequestor call 360-705-6705. Teletype (TTy) users please bial Zt .t. <br />REV 54 A]fO $/27/2U Page 1 of 1