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Certain applications may incur a Real Estate Excise Tax liability for the seller of the water rights. The Department <br />of Revenue has requested notification of potential taxable water right related actions and therefore may be <br />provided with a copy of this request. For further information, contact: <br />Department of Revenue <br />Real Estate Excise Tax <br />PO Box 47477 <br />Olympia, WA 98504-7477 <br />Phone (360) 570-3265 <br />12. Signatures: <br />I certify that the information above is true and accurate to the best of my knowledge. I understand that in order <br />to process my application, I hereby grant staff from the Department of Ecology or the County Water <br />Conservancy Board access to the above site(s) for inspection and monitoring purposes. If assisted in <br />preparing this above application, I understand that all responsibility for the accuracy of the information rests <br />with me. <br />Cory Wright - County Commissioner <br />Applicant Printed Name — Title Applicant Signature <br />Cory Wright - County Commissioner <br />Water Right Holder Printed Name Water Right Holder Signature <br />Cory Wright - County Commissioner <br />Landowner of Existing Place of Use <br />Printed Name <br />(Date: MMIDDIYYYY) <br />(Date: MMIDDIYYYY) <br />Landowner of Existing Place of Use Signature (Date: MMIDDIYYYY) <br />Landowner of Proposed Place of Use Printed Landowner of Proposed Place of Use Signature (Date: MMIDDIYYYY) <br />Name <br />Authorized Representative <br />Printed Name <br />Authorized Representative Signature <br />(Date: MMIDDIYYYY) <br />ECY 040-1-14 (Rev 03-2021) Page 11 of 16 <br />