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Ratdfiil{e <br />Woshington Stote <br />Form 64 0100 <br />Levy Certification <br />Submit this document, or something similar; to the county legislative <br />authoraty on or before November 3O 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 levles under RCW 84.52.070. <br />(District name), <br />ln accordance with RCW 84.52.020, I Dustin Kinley (Name), <br />Dir€ctor of Fiscal Services, ESD 105 (Title), for Cle Elum-Roslyn School Dlstrict No. {04 <br />do hereby certify to the Kittltas (Nome of county) County legislative authority <br />(Commissioners, Council, 9oard, etc.) of said district requeststhat the Board <br />that the following levy amounts be collected in <br />To request <br />or call 360- <br />(Year of collection) as provided in the district's2025 <br />budget, which was adopted following a public hearing held on 07l2sl2o24 (Dote of public hearing). <br />lar levies <br />Excess levies <br />Examples of other levy types may inc EMS, school dlstrict transportation, or construction levies <br />Examples of other amounts may include levy error correchon or adjudicated refund amount. Please include <br />a description when usi the "other"options <br />Signature:Datez /4:j-8:H2? <br />please complete the form dor.wa.gov/AccessibilityRequest <br />dial 7l l. <br />Page 1 of 1 <br />this document in ternate format, <br />705-67 05.Teletype (TTY) users please <br />Total certified levy reguest <br />amount, which includes the <br />amounts below. <br />Adm inistrative refund amount <br />Non-voted bond debt amount <br />Other* <br />General levy Other levy*Levy <br />1,S00,000.003;400,000.00Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />Administrative refund <br />amount <br />Other+ <br />General <br />(n/a for school <br />di stricts) <br />Enrichment <br />(sc hoo I <br />districts only) <br />Other levy*IBondCap. projectLevy <br />REV 54 o1o0 18123/221