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Ra*ffiit@ <br />Woshlngton Stote <br />Fgnrn 64 O1OG <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 />!n accordance with RCW 84.52 .A2O,l Tracey Epenesa (Name), <br />clerk ffiile),1or Kittitas County cemetery Dist #x pistrict name), <br />do hereby certify to the Kittitas (Name of county) County legislative authority <br />that the commissioners $ommissioners, Council, Board, etc.) of said district requests <br />that the following levy amounts be colleclg6 ;n 2023 (Year of collection) as provided in the district's <br />budget, which was adopted following a public hearing held on ttlt0l2a22 (Date of public heoring). <br />iar levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construction levies. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. Please include <br />a descripti <br />Signature: <br />on n using the "other"options. <br />Date: It'tO-A? <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />$ 17,ooo.o0 <br />Administrative refund amount $ o.or <br />Non-voted bond debt amount <br />Other* <br />General levrT Other levy*Levy <br />Totalcertified levy <br />request amount, <br />which includes the <br />amounts below. <br />t- <br />Administrative refund <br />amount <br />Other* <br />General <br />(nla for school <br />d istricts) <br />Enrichment <br />(school <br />districts only) <br />Cap" project <br />O.ther <br />BondLevy <br />To reque_sJ !1i1{ggument in an alternate format, please complete the form dor.ur_a.Lov/AccessibilityReguest <br />or call 360-705-6705. Teletype (TTY) users please dial 7t 1. <br />REV 64 }LOo (8/27/2Ll page 1 of 1