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Ra"idHlit@ <br />Washington Stote <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 />ln accordance with RCW 84.52.020, I <br />freasurer <br />lason Adler (Name), <br />(Title), for Kittitas County Public Hospital Dist. No. 2 (District name), <br />do hereby certify to the Kittitas (Name of county) County legislative authority <br />(Commissioners, Council, Board, etc.) of said district requests <br />2 2.t <br />complete the form dor.wa.gov/Accessi bi lityRequ est <br />that the <br />1025that the following levy amounts be collected in (Year of collection)as provided in the district's <br />Board of Commissioners <br />a description whqn using the "o!her" options. <br />Sign^tur"r O"t", <br />To request tf,i(Oocum(nt in an alternate format, please <br />or cal[ 360-705-6705.Teletype (TTY) users please dial 71 <br />budget, which was adopted following a public hearing held on LOl21l2024 {Dote of public hearing) <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 />1 <br />EMS <br />3,000,000.00Total certified levy request <br />amount, which includes the <br />amounts below. <br />3,000,000.00 <br />Ad mi nistrative 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 />(nla for school <br />d rstricts) <br />Enrichment <br />(school <br />districts only) <br />Other <br />Bond Cap. project <br />* <br />Levy <br />REV 54 O1oA (8/231221 Page 1 of 1