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Ra"idfftiE@ <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 />Woshington Stote <br />Fornr &t4 t12*43 <br />ln accordance with RCW 94.52 .OZO,l John Sinclai, (Nome), <br />Fire chief ftiile), ye; Kittitas County Fire District z lDistrict name), <br />do hereby certify to the Kittitas (Name of county) County legislative authority <br />that the Board of Fire commissioners (commissioners, council, Boord, etc.) of said district requests <br />that the following levy amounts be collected in 2923 (Year of collection)as provided in the district's <br />budget, which was adopted following a public hearing held on LVtol2lzz (Date of public hearing). <br />ular levies <br />Excess levies <br />*Examples of oth er levy types may include EMS, school district transportation, or construction levies. <br />Examples of other amounts may i ude levy error correction or adjudicated refund amount. Please include <br />a description when usin e"er ons <br />Signature:Date: la * aae-z <br />To s <br />or cal 705 <br />document in an alternate format, please complete the form dor.wa.gov/AccessibilityRequest <br />-6705.Teletype (TTY) users please dial711 . <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />s 8,000,000.00 <br />Ad ministrative refu nd a mount <br />Non-voted bond debt amount <br />Other* <br />General levy Othe,r levy*Levy <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />S 4zo,ooo.oo <br />Administrative refund <br />amount <br />Other* <br />General <br />{n/a for sch.ool <br />districts) <br />Enrichment <br />{school <br />districts only)ffLevyCap. projectBond <br />REV 64 0700 (8/27/21)Page 1 of 1