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Re{,[fflit@ <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 />Woshington Stote <br />brm 64 0100 <br />do hereby certify to the kt#,+cqf Name of county) County legislative authority <br />that the CAlr',n"n\ttiOne,,j $ommissioners, Council, Boord, etc.) of said district requests <br />that the following levy amounts be collected in 2OZ5 ffear of collectionl as provided in the district's <br />budget, which was adopted following a public hearing held on tt ft, /Zf pote of public hearing). <br />ln accordance with RcW 84.s2 .o2o, t CA"f lu#" Gn (Name), <br />& 4( @istrict name),%rw\,vEiofta{(ritte), for f<ifrA'f* ffi . <br />ular levies <br />Total certified levy request <br />amount, which includes the <br />amounts below. <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 />on when usin th e "other" options; descriRti <br />- Signature:Date: ll,71,a4 <br />To request this document Iternate format, please com plete the form d o r.wa.gov/Accessi bi I ityReq uestana <br />or call 360-7 05-6705. Teletype <br />torooo <br />aministrative refund amount <br />4Non-voted bond debt amount <br />Other* <br />General levy Other levy*Levy <br />L-J <br />lvA <br />Total certified levy <br />requegt amount, <br />which includes the <br />amounts below. <br />MTAdministrative refund <br />amount <br />MAOther* <br />General <br />(nla for school <br />districts) <br />Enrichment <br />(school <br />districts only) <br />Other le <br />Cap. projectBondLevy <br />* <br />REV 64 OLOO (8/27l2Ll <br />(TTY) users please dial 711. <br />Page 1 of 1