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Ra$iffil:;(e <br />Woshington Stote <br />Farym 6& *&W* <br />Levy Certification RiEeHfvFD c v <br />Submit this document, or something simitar, to the .o""ffEHuf,t$rfrffip ' T- <br />authoritv on or before November 30 0f the vear prepffi$Ffilp"y.qnqvwhich <br />the levy amounts are to be collected. "'I'r^u t'uuj*ilYASSESsOfi <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,l &Cittwi,"A_ LA06-ytd{_. (Name), <br />&vtlwq - Qtta-nu"J rrry, ffitte), rc, Clhlws b 6w Prakc,h tnt f>ts!.6 (District name),J <br />do hereby certify to the {;+f, f^r: (Name of county)county legislative authority <br />that the ( an |nd s*iavttAa Pommissioners, Council, Boord, etc.) ofsaid district requests <br />that the following levy amounts be collected in )oJ3 ftear of collection)as provided in the district,s <br />budget, which was adopted following a public hearing held on tt/a> f AU (Dote of pubtic hearing). <br />lar levies <br />Excess levies <br />*Examples of other I evy types may include EMS, school distri ct transportation, or construction levies <br />Examples of other amounts may include revy error correction or adjudicated refund amount. please include <br />a desc <br />Signat <br />To req <br />or call <br />ription hen using the r" options. <br />)z <br />s document in an alternate fo rmat, <br />360-705-6705. Teletype (TTy) users <br />ure: <br />ue5 <br />Date: <br />please <br />dial71 <br />do r,wa. gov/Access i b i I ityRequest <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />cl I 5, oao <br />Admin istrative refund a mount tt)41 ,uL <br />Non-voted bond debt amount 4 <br />Other*4* <br />Levy General levy Other levyx <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />-€* <br />Administrative refund <br />amount <br />z) <br />Otherx e <br />General <br />(n/a for school <br />districts) <br />Enrichment <br />(schoo,l <br />districts only) <br />Bond Cap. project <br />*OtherLevy <br />REV 64 OIOO (8/27/2!) <br />please <br />complete the form <br />Page 1 of 1