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Department of <br />Revenue c- <br />Washington State <br />Form 64 0100 <br />Leery 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 1R$f($FWVZp, <br />OCT 3 12023 <br />� Kliillf�g CHOTYASSESS OR <br />In accordance with RCW 84.52.020, 1 �I VV�� (Name), <br />'( Y (Title), for(District name), <br />do hereby certify to the[El v-i o <br />(Name of county) County legislative authority <br />that the i (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 />budget, which was adopted following a public hearing held on hOl V? I (Date of public hearing). <br />Regular levies <br />Levy <br />Total certified levy request��� <br />amount, which includes the <br />amounts below. <br />General levy <br />Otherlevy* <br />Administrative refund amount <br />Non -voted bond debt amount <br />Other* <br />Excess levies <br />-txampies oT 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 />a description when using the "other" options. <br />Signature: H _��L Date: <br />To request this document in an alternate format, please complete the form dor.wa. ovlAccessibilit Re uest <br />nr rail 'AAn-7Ar%-A7nS Talatvrno (TTY1 i 1«►rc hlaacP dial 711 <br />