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Raildfitit@ <br />Woshington 5tote <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 (Nome), <br />(Title), f or (District name), <br />do hereby certify to the (Name of county) County legislative authority <br />that the (Commissioners, Council, Board, etc.) of said district requests <br />that the following levy amounts be collected in (Year of collection) as provided in the district's <br />(Date of public hearing).budget, which was adopted following a public hearing held on ttlr2l2o24 <br />lar levies <br />Excess levies <br />*Examples of other levy types may in clude EMS, school d istrict tra nsportation, or co nstruction levies. <br />Examples of oth ounts may inclu de levy error correction or adjudicated refund amount. Please include <br />a description "other" options. <br />Signature:Date: <br />ment in an alternate format, Please form dor.wa.gov/Accessibil ityRequest <br />Adams <br />of Roslyn <br />Council <br />uestTo req <br />or call -67}5.Teletype (]-fY) users please dial zt t. <br />500,000.00Total certified levy request <br />amount, which includes the <br />amounts below. <br />Admi nistrative refund amount <br />Non-voted bond debt amount <br />Other* <br />Other levy*General levyLevy <br />L-l <br />31,716.00Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />Administrative refund <br />amount <br />Other* <br />General <br />(nla f or school <br />d ist ri cts ) <br />Enrichment <br />(school <br />districts only) <br />Cap. projectBondLevy <br />Other lev <br />REV 54 ALOO (8123/221 Page 1 of 1