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Rev6ffilt@ <br />Washington Stote <br />Form 54 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 />(Name),ln accordance with RCW 84.52.020, I Dustin Kinley <br />rector of Fiscal Servlces, ESD 105 (Title/, for <br />Kittitas <br />School District No.028 (District name), <br />do hereby certify to the <br />Board <br />(Nome of county) County legislative authority <br />(Commissioners, Council, Board, etc.) of said district requeststhat the <br />2025that the following levy amounts be collected in (Year of collection) as provided in the district's <br />budget, which was adopted following a public hearing held on 0712{2024 (Dote of public heoring). <br />lar 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 when sing the "other"ns, <br />Signature:Date: fi,79',2e2y <br />To req <br />or call <br />uest this ent in an ate form at, please com plete the form dor.wa.gov/Accessibil ityRequest <br />360-705-6705. Teletype (TTY) users please dial 7t I <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />Administrative refund amou nt <br />Non-voted bond debt amount <br />Other* <br />General levy Other levy*Levy <br />L-J <br />495,000.00Total 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 />districts ) <br />Enrichment <br />( sc hool <br />districts only) <br />Other <br />Bond Cap. projectLevy <br />REV 64 0tO0 18/23/221 Page 1 of 1