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Department of <br />Revenue @ 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 />Washington Stote <br />Form 64 0100 <br />ln accordance with RCW 84.52.020, I <br />Chief Financial Officer <br />lason Adler (Name), <br />(Title), for Kittitas county Public Hospital Dist. No. 1 (District nome), <br />do hereby certify to the Kittitas <br />Board of Commissioners <br />(Nsme of county)County legislative authority <br />(Commissioners, Council, Boord, etc.) of said district requeststhat the <br />that 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 (Date of public hearing) <br />ar levies <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construction levies. <br />2025 <br />Examples of other amounts may include levy error correction or adjudicated refund amount. Please include <br />a description wlgn using the/'other" options.i,ii"-i",,"7:'W[X "'* <br />s"r". pf ,/f,o,l <br />To request this docu4ent in an alternate format, please complJt" theform dor.wa.gov/AccessibilityRequest <br />or call 360-705-6705. Teletype (TTY) users please dial 71 1 . <br />REV 64 at00 (8/231221 Page 1 of I <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />20,000.00 <br />37.t3Administrative refund amount <br />Non-voted bond debt amount <br />Other* <br />General levyLevy Other 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 />districts) <br />Enrichment <br />(school <br />districts only) <br />Other I <br />Bond Cap. project <br />* <br />Levy