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Department of <br />Revenue @ <br />Washington State <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 RCM164.Lq'9ffb <br />In accordance with RCW 84.52.020, <br />NUV 17 2023 <br />r MIKE HOUGARDY <br />I e " A iCa -C (Name), KITTITAS COUNTY ASSESSOR <br />(Title), for ��lt CD.ivC ��] �i11`r1�]i5{` (District name), <br />do hereby certify to thei �'IS <br />(Name of county) County legislative authority <br />that the tS�ll1rL.1 (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 — -a0213 (Date of public hearing). <br />Regular levies <br />Levy <br />General levy <br />Otherlevy* <br />Total certified levy request <br />51 L14-1) m)'K- I fq <br />amount, which includes the <br />amounts below. <br />Administrative refund amount <br />Non -voted bond debt amount <br />Other* <br />Excess levies <br />*Examples of other levy types may include EMS, school district transportation, or construction levies. <br />Examples o her amounts may include levy error correction or adjudicated refund amount. Please include <br />a descrip on v+hen u i g t e" then" options. <br />Signature• L Date: 1 °l 2 2L <br />To request thiDdocument in an al nate format, please complete the form dor.wa. ov/Accessibilit Re nest <br />or call 360-705-6705. Teletype (TTY) users please dial 711. <br />REV 64 0100 (8/23/22) Page 1 of 1 <br />