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Depariment of <br />Revenue V <br />Washington State <br />Form 64 0100 <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 />In accordance with RCW 84.52.020, I JDustin Kinley <br />ame), <br />I Director of Fiscal Services, ESD 10S (Title), for JCle Elum-Roslyn School District No. 404 1 (District name), <br />do hereby certify to the Kittitas (Name of county) County legislative authority <br />that the Board (Commissioners, Council, Board, etc.) of said district requests <br />that the following levy amounts be collected in 2025 (Year of collection) as provided in the district's <br />budget, which was adopted following a public hearing held on 07/25/2024 (Date of public hearing). <br />lar levies <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />Administrative refund amount <br />Non -voted bond debt amount <br />Other* <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 when using the "other" options. <br />Signature: f Date: <br />To request this document in arraAernate format, please complete the form dor.wa.goy/AccessibilityRequest <br />or call 360-705-6705. Teletype (TTY) users please dial 711. <br />REV 64 0100 (8/23/22) Page 1 of 1 <br />