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R3?ffiil$(@ <br />Wcshington Srote <br />Form 54 0100 <br />ln accordance with RCW 84.52.020, I <br />do hereby certify to <br />that the <br />that the following levy amounts be collected in <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 />(Title), f or (District name), <br />(Nome of county) County legislative authority <br />{Commissioners, Council, Boqrd, etc.)of said district requests <br />taa tl (Year ol as provided in the district's <br />(Date of public hearing).budget, which was adopted following a public hearing held on <br />lar levies <br />Excess levies <br />*Examples 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 />To <br />or <br />on when usi the "other"ns <br />Dat€:l/,1)-e3 <br />alternate format,please complete <br />dial 7l 1 . <br />the form dor.wa.gov/AccessibilityRequest <br />Total certiffed lew request <br />amount,' which includes the <br />amounts below.y'0, /27 g- <br />Administrative refund amount <br />Non-voted bond debt amount <br />Otherr <br />General levy 0ther levy*Levy <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />Administrative refund <br />amount <br />Other* <br />General <br />{n/a tor school <br />districts) <br />Enrichment <br />(sch ool <br />clistt'icts only) <br />Other levy*TLevyBondCap. project <br />REV 64 0100 (8/231221 <br />(TTY) users please <br />Page 1 of 1