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ReiilffllI@ <br />Woshington 5cote <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 />(Name), <br />(District name), <br />ln accordance with RCW 84.52.020, I Helgeson <br />Fire €hief (Title), for Kittitas County Fire District #3 <br />do hereby certify to the Kittitas (Name of county)County legislative authority <br />(Commissioners, Council, Board, etc.) of said district requeststhat the <br />that the following levy amounts be collected in <br />budget, which was adopted following a public hearing held on <br />Regular levies <br />To req <br />or call <br />Commissioners <br />2025 (Year of collection) as provided in the district's <br />ttlt2l2s24 (Date of public hearing) <br />Excess levies <br />*Exam es other levy types may include EMS,ool 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 />Date tl- fJ,art <br />uest this document in an alternate format, please complete the form dor.wa.gov/AceessibilityRequest <br />360-705-6705. Teletype (TTY) users please dial 71 1. <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />400000 <br />Administrative refund amount <br />Non-voted bond debt amount <br />Other* <br />General levy Other levy*Levy <br />L-J <br />Totalcertified 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 />d istricts) <br />Enrichment <br />{school <br />districts only) <br />Cap. projectBond <br />Other <br />Levy <br />REV 64 oLoo (8/23/22|Page 1 of 1