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Department of <br />R&enue <br />Washington state <br />Levy Certification <br />Submit this document to the county legislative authority on or before November 30 of the year preceding <br />the year in which the levy amounts are to be collected and forward a copy to the assessor. <br />Qt'�n� � <br />In accordance with RCW 84.52.020 I J 1^ f✓ �^ 1�1 <br />L1 (Name) <br />`Q- C k' e � , for 0 � �HS �+�1n.�, � �� c C Nd l'i't f I do hereby certify to <br />(Title) (Distric Name) <br />the K11 +I 'f 1 �y%s County legislative authority that the F ire 6M/A 1 5� 5 i r5 <br />(Name of County) (Commissioners, Council, Board, etc.) <br />of said district requests that the following levy amounts be collected in 01 provided in the district's <br />II (Year ofCollccyvn) <br />budget, which was adopted following a public hearing held on I — 17 . <br />(Date of Public Hearing) <br />Regular Levy: <br />Excess Levy: <br />Refund Levy: <br />(State the totral dollar amount to be levied) <br />(State the total dollar amount to be levied) <br />(State the total dollar amount to be levied) <br />Signature: �. <br />Date:Tp� —1,5 — / 7 <br />To ask about the availability of this publication in an alternate format for the visually impaired, please call (360) 705-6715. <br />Teletype (TTY) users, please call (360) 705-6718. For tax assistance, call (360) 534-1400. <br />REV 64 0100e (w) (2/21/12) <br />