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RaTefiiit@ <br />Washington State <br />F*ri'n 64 {330fi <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 />tn accordance with Rcw 84,s2.020, I C.h.i: Hal6efo ": (Name), <br />f I as C",l^l eF ffftte), ror K i fli{ns Co,.:,.rly fie Dlrk 3 {District name}, <br />do hereby certify to the Kitilfs (Name of countylCounty legislative authority <br />that the Bo<co oQ C-**i:iotu€€5 ftommissioners, Council, Board, etc.) of said district requests <br />that the following levy amounts be collected in OOa\ ffeor af cotlectionlas provided in the district's <br />budget, which was adopted following a public hearing held on t t' l3 -a3 (Date of public hearing). <br />ar 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 description nu the "other" options <br />Sign Date: ll- 13')3 <br />To request this document in an alternate format, please complete the form elql-\.ryagqvlA_q,(e-s,rlbli[yiequest <br />or call 360-7A5-6705. Teletype (TTY) users please dial 71 1. <br />REv 64 o70a (8/27/21| Page 1 of 1 <br />[sqy CmefiES eRry ffier@f <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />35o,oot) <br />Administrative refund a mount <br />Non-voted bond debt amount <br />Other* <br />[ry EM <br />(tn&tugffiCIdffiri Eeffil <br />tffi <br />(6ffiod <br />dMctsmhd) <br />epp@ ffi€rhn.f <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />Administrative refund <br />amount <br />Other*