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Raiilhlii[(e Levy Certification <br />Submit this document, or something similar, to the county leglslafive <br />authority on or before November 30 of the year precedlng the year in which <br />the levy amounts are to be colleeted. <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 />\,Voshington Stote <br />Form 64 0100 <br />ln accordance with RCW 84.52.A2O,1 (Name), <br />(Title),tar (District name), <br />do hereby certify to the (Name of county) County legislative authority <br />that the (Commissioners, Council, Board, etc.) af said district requests <br />that the following levy amounts be collected in Tf,LLI (Year of collection) as provided in the district's <br />budget, which was adopted following a public hearing held on t(>ht z3 (Date of public hearing). <br />lar levies <br />Excess levies <br />'Examples of other levy types may include EMS,I district transportation, or construction levies. <br />Exampies of other amounts may include levy error correction or adjudicated refund amount. Please include <br />a descri whe n using 'bther" options. <br />Signature:Date: <br />t\ <br />t <br />1 <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />.$L{t {,}tnrp,eD <br />Ad ministrative refund amount <br />Non-voted bond debt amount <br />Other* <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />L--J <br />Administrative refund <br />amount <br />Other* <br />Gencral <br />(rr/a {or :,clrr.rol <br />cli:,trrct.;) <br />Enrichment <br />{sc lror"rI <br />rlistricts only) <br />OtherLevyBond <br />{.- <br />Cap. profect <br />To regqqsJ this document in an alternate format, please complete the form dor.wa.gov/AcqessibilityRequest <br />nr rall 16n-7nq-670{ Trrlptvne (TTVI lrqFrq nlaace rlial 71I