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Department of �c I7)
Revenue
Washington State
REAL ESTATE EXCISE TAX AFFIDAVIT
This form is your receipt
PLEASE TYPE OR PRINT CHAPTER 82.45 RCW—CHAPTER 458-61A WAC when stamped by cashier.
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED
(See back of last page for instructions)
❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name.
II Name Quality I oan Service Corp of Washington n Name Federal National Mortaaae Association
x �041 lie- f('ra//UJ) W ("Fannie Mae"). a corporation orpani7ed and existina **
e4 0
Mailing Address 108 1st Ave South. Suite 202 Mailing Address 14221 Dallas Parkway Suite 1000
City/State/Zip Seattle. WA 98104 City/State/Zip Dalla TX 75254
Phone No.(including area code) Phone No.(including area code)
® Send all property tax correspondence to:®Same as Buyer/Grantee List all real and personal property tax parcel account List assessed value(s)
numbers—check box if personal property
Name A.P.N. 40006/990400257
Mailing Address n
City/State/Zip n
Phone No.(including area code) n
IN Street address of property: 636 MONTGOMFRY I N PORT LUDLOW WA 98365
This property is located in Jefferson County
❑Check box if any of the listed parcels are being segregated from another parcel,are part of a boundary line adjustment or parcels being merged.
Legal description of property(if more space is needed,you may attach a separate sheet to each page of the affidavit)
LOT 57,AREA 2,PORT LUDLOW NO. 1,AS PER PLAT RECORDED IN VOLUME 5 OF PLATS,PAGES 26
THROUGH 32 INCLUSIVE,RECORDS OF JEFFERSON COUNTY,WASHINGTON.SITUATE IN THE
COUNTY OF JEFFERSON,STATE OF WASHINGTON.
**under the laws of the United States of America
® Select Land Use Code(s): EI List all personal property(tangible and intangible)included in selling
111-Household,single family units I price.
enter any additional codes: -0-
(See back of last page for instructions)
YES NO
Was the seller receiving a property tax exemption or deferral under ❑ r
chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior
citizen,or disabled person,homeowner with limited income)?
® YES NO If claiming an exemption, list WAC number and reason for exemption:
Is this property designated as forest land per chapter 84.33 RCW? ❑ 12 WAC No. (Section/Subsection) 458-61A-208(4)
Is this property classified as current use(open space,farm and ❑ 12
agricultural,or timber)land per chapter 84.34? Reason for exemption
Foreclosure of Deed of Trust-489945
Is this property receiving special valuation as historical property ❑ ri
per chapter 84.26 RCW?
If any answers are yes,complete as instructed below.
Type of Document Trustees Deed Upon Sale
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE)
NEW OWNER(S):To continue the current designation as forest land or Date of Document 4/22/15
classification as current use(open space,farm and agriculture,or timber)land, Gross Selling Price $ 260,000.00
you must sign on(3)below.The county assessor must then determine if the
land transferred continues to qualify and will indicate by signing below.If the *Personal Property(deduct) $
land no longer qualifies or you do not wish to continue the designation or 260,000.00
classification,it will be removed and the compensating or additional taxes will Exemption Claimed(deduct) $
be due and payable by the seller or transferor at the time of sale.(RCW Taxable Selling Price $ 0.00
84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Excise Tax : State $ 0.00
your local county assessor for more information. 0.0050 Local $ 0.00
This land ❑does ❑does not qualify for continuance.
*Delinquent Interest: State $
Local $
DEPUTY ASSESSOR DATE *Delinquent Penalty $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) 0.00
NEW OWNER(S):To continue special valuation as historic property, Subtotal $
sign(3)below.If the new owner(s)does not wish to continue,all *State Technology Fee $ 5.00
additional tax calculated pursuant to chapter 84.26 RCW,shall be due and
payable by the seller or transferor at the time of sale. *Affidavit Processing Fee $ 5.00
(3) OWNER(S)SIGNATURE Total Due $ 10.00
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
I CERTIFY UNDER PENAL OF PERJURY THAT THE FOREGOING IS TRUE AND_CORRECT.
Signature of � " " � °" Signature of �
/t,,_y
Grantor or Grantor's Agent V' z" Grantee or Grantee's Agent Q t�/I�(� �P/ , j
Name(print) Janice Stavee Name(print) Sierra Herbert-West
Date&city of signing: 4/22/15 Seattle Date&city of signing: 4/22/15 Seattle
Perjury:Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a maximum term of not more than five years,or by
a fine in an amount fixed by the court of not more than five thousand dollars($5,000.00),or by both imprisonment and fine(RCW 9A.20.020(1C)).
.
_,_�•? 4; s ;_: *4 a/° , 1= I 0{; l�� t: THIS SPACE-TREASURER'S USE ONLY COUNTY ASSE`� ,