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Depattrn m of
<br />Revenue
<br />bYnshrRgton scats
<br />REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt
<br />PLEASE TYPE OR PRINT CHAPTER 82.45 RCW — CHAPTER 458-61A WAC when stamped by cashier.
<br />THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED
<br />El(See back oflast page for instructions)
<br />Check box if aniel sale of If multiple cnwriem, list percentage ofownership next to name.
<br />Street address of property: 1790 Berry Road. Ellensburn. WA 98926
<br />This property is located in Kittitas County a
<br />❑ Check box ifany of the listed parcels are being segregated from another parcel, are part oft boundary line adjustment or parcels being merged.
<br />Legal description of property (if more space is needed, you may attach a separate sheet to each page of the affidavit)
<br />See attached sheet
<br />® Select Land Use Code(s):
<br />t - Undwal. ;led UA ('.no only]
<br />enter any additional codes:
<br />(See back of last page for instructions)
<br />YES NO
<br />Was the seller receiving a property tax exemption or deferrer) under ❑ ❑
<br />chapters 84.36, 84.37, or 84.38 RCW (nouprofit alludzation, senior
<br />citizen, or disabled person, homeownerwith limited inaxmer
<br />YES NO
<br />Is finis property designated as forest land per chapter 84.33 RCW? ❑ ❑
<br />Is this property classified as currant use (opm space, farm and ❑ ❑
<br />agricultural, ortimber) land per chapter 84.34?
<br />Is this property receiving special valuation as historical property ❑ ❑
<br />perdnapta 84.26RCW?
<br />If arty answers are yes, complete as instructed below
<br />(1) NOTICEOFCON (NUANCE (FDRFSrLANDORCURRENTUsp
<br />NEW OWNER(S): To continue the current designation as forest land or
<br />classification as current use (open space, tstm and agriculture, or timber) land,
<br />you must sign on (3) below. The county assessor must then detemnine if the
<br />land transferred continues to qualify and will indicate by signing below. Ifthe
<br />land no longer qualiSes oryou do not wishto continue the designation or
<br />classification, it will be removed and the compensating or additional taxes will
<br />be due and payable by the seller or transferor at the time of sale. (RCW
<br />84.33.140 or RCW 84.34.108). Prior to signing (3) below, you may comad
<br />your local county assessor for more infomtation.
<br />This land ❑does ❑ does not qualify for continuance.
<br />.[ u 1 r AL=.I. QUA
<br />(2) NOTICE OF COMPLIANCE (IHSTORIC PROPERTY)
<br />NEW OWNER(S): To continue special valuation as historic property,
<br />sign (3) below. If the new owner(s) does not wish to continue, all
<br />additional tax calculated pursuant to chapter 84.26 RCW, shall be due and
<br />payable by the seller or transferor at the time of sale.
<br />(3) OWNER(S) SIGNATURE
<br />PRINT NAME
<br />List all personal property (tangible and intangible) included in selling
<br />price.
<br />If claiming an exemption, list WAC number and reason for exemption:
<br />WAC No. (Section/Subsection)
<br />Reason for exempti on
<br />Type of Document Statutory Warranty Deed
<br />Date of Document
<br />Gross Selling Price $
<br />Name Aaron and Stephanie Royer
<br />*Personal Property (deduct) $
<br />Name Mtas County Public Works
<br />.Waa
<br />Taxable Selling Price $
<br />9.000.00
<br />°
<br />zm:) �
<br />115.20
<br />Mailing Address 1790 Berry Road
<br />Ci lStatwZi Ellensburg, WA, 98926
<br />ty p
<br />22.50
<br />Mailing Address 411 N. Ruby SL
<br />CitylStatelZip Ellensburg, WA 98926
<br />Phone No. (including area code) (509) 899-4197
<br />Local $
<br />Phone No. (including area code) 509 962-7523
<br />Sendai property tax correspondence to: ❑� Same as Buyer/Granteenumbers
<br />Name
<br />List all real and personal property tax parcel account
<br />— check bar if personal property
<br />806336 ❑
<br />List assessed value(s)
<br />$9,m
<br />Mailing Address
<br />Citymate by
<br />Phone No. (including area code)
<br />❑
<br />❑
<br />❑
<br />Street address of property: 1790 Berry Road. Ellensburn. WA 98926
<br />This property is located in Kittitas County a
<br />❑ Check box ifany of the listed parcels are being segregated from another parcel, are part oft boundary line adjustment or parcels being merged.
<br />Legal description of property (if more space is needed, you may attach a separate sheet to each page of the affidavit)
<br />See attached sheet
<br />® Select Land Use Code(s):
<br />t - Undwal. ;led UA ('.no only]
<br />enter any additional codes:
<br />(See back of last page for instructions)
<br />YES NO
<br />Was the seller receiving a property tax exemption or deferrer) under ❑ ❑
<br />chapters 84.36, 84.37, or 84.38 RCW (nouprofit alludzation, senior
<br />citizen, or disabled person, homeownerwith limited inaxmer
<br />YES NO
<br />Is finis property designated as forest land per chapter 84.33 RCW? ❑ ❑
<br />Is this property classified as currant use (opm space, farm and ❑ ❑
<br />agricultural, ortimber) land per chapter 84.34?
<br />Is this property receiving special valuation as historical property ❑ ❑
<br />perdnapta 84.26RCW?
<br />If arty answers are yes, complete as instructed below
<br />(1) NOTICEOFCON (NUANCE (FDRFSrLANDORCURRENTUsp
<br />NEW OWNER(S): To continue the current designation as forest land or
<br />classification as current use (open space, tstm and agriculture, or timber) land,
<br />you must sign on (3) below. The county assessor must then detemnine if the
<br />land transferred continues to qualify and will indicate by signing below. Ifthe
<br />land no longer qualiSes oryou do not wishto continue the designation or
<br />classification, it will be removed and the compensating or additional taxes will
<br />be due and payable by the seller or transferor at the time of sale. (RCW
<br />84.33.140 or RCW 84.34.108). Prior to signing (3) below, you may comad
<br />your local county assessor for more infomtation.
<br />This land ❑does ❑ does not qualify for continuance.
<br />.[ u 1 r AL=.I. QUA
<br />(2) NOTICE OF COMPLIANCE (IHSTORIC PROPERTY)
<br />NEW OWNER(S): To continue special valuation as historic property,
<br />sign (3) below. If the new owner(s) does not wish to continue, all
<br />additional tax calculated pursuant to chapter 84.26 RCW, shall be due and
<br />payable by the seller or transferor at the time of sale.
<br />(3) OWNER(S) SIGNATURE
<br />PRINT NAME
<br />List all personal property (tangible and intangible) included in selling
<br />price.
<br />If claiming an exemption, list WAC number and reason for exemption:
<br />WAC No. (Section/Subsection)
<br />Reason for exempti on
<br />Type of Document Statutory Warranty Deed
<br />Date of Document
<br />Gross Selling Price $
<br />9,000.00
<br />*Personal Property (deduct) $
<br />Exemption Claimed (deduct) $
<br />Taxable Selling Price $
<br />9.000.00
<br />Excise Tax: State $
<br />115.20
<br />0.0025 Local $
<br />22.50
<br />*Delinquent Interest: State $
<br />Local $
<br />*Delinquent Penalty $
<br />Subtotal S
<br />137.70
<br />*State Technology Fee S
<br />5.00
<br />*Affidavit Processing Fee $
<br />Total Due $
<br />142.70
<br />A MINIMUM OF $10.00 IS DUE IN FEE(S) AND/OR TAX
<br />*SEE INSTRUCTIONS
<br />I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
<br />Signature of
<br />Grantor or Grantor's Agent
<br />Name (print)
<br />Date & city of signing:
<br />Signature of
<br />Grantee or Grantee's Agent
<br />Name (print)
<br />Date & city of signing:
<br />Perjury: Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a maximum term of not more than five years, or by
<br />a fine in an amount fixed by the court of not more than five thousand dollars ($5,000.00), or by both imprisonment and fine {RCW 9A.20.020 (1Q.
<br />REV 84 0001a (119/14) THIS SPACE - TREASURER'S USE ONLY DEPT. OF REVENUE
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