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Department of <br />Revenue F <br />Washington State <br />Forrei 64. GI Goa <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 />In accordance with RCW 84.52.020, 1 <br />Clkri `) <br />H���F�Sa <br />(Name), <br />�lQk <br />(Title), for <br />I�,i���AS <br />Nky iC� oi�� 1 (Districtname), <br />do hereby certify to the K144,\s <br />(Name of county) County legislative authority <br />that the QoeiD a� Con�miSidNE� (Commissioners, Council, Board, etc.) of said district requests <br />that the following levy amounts be collected in c�0al4 (Year of collection) as provided in the district's <br />budget, which was adopted following a public hearing held on [ t- 13'a3 (Date of public hearing). <br />Raaular Ipvies <br />h9' <br />OiOP <br />Total certified levy request <br />amount, which includes the <br />amounts below. <br />3CJO��O� <br />Administrative refund amount <br />Non -voted bond debt amount <br />Other* <br />Excess levies <br />@aDg0 <br />Q <br />uom <br />Maw oo <br />� <br />oo <br />moo <br />f <br />Total certified levy <br />request amount, <br />which includes the <br />amounts below. <br />Administrative refund <br />amount <br />Other* <br />*Examples of other levy types may tncluae tivl5, scnooi aistrici iransporiauon, or cunsuucuun ieviet'. <br />Examples of other amounts may include levy error correction or adjudicated refund amount. Please include <br />a descriptio�he���he us'";ner." options. <br />Signature.E� Date: <br />To request this document in an alternate format, please complete the form dor.wa.gov/AccessibilityRequest <br />or call 360-705-6705. Teletype (TTY) users please dial 711. <br />REV 64 0100 (8/27/21) Page 1 of 1 <br />