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Woshmgwn 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.
0 Name Kris G.Andersen,Personal Representative of the Estate of A Name Kris G.Andersen,Trustee of the Eleanor T.Andersen Trust
a'
Arnold C.Andersen
7-1 ailing Address 1027 Walnut St Mailing Address 1027 Walnut St
o City/State/Zip Edmonds,WA 98020 pq City/State/Zip Edmonds,WA 98020
Phone No.(including area code) (425)771-6384 Phone No.(including area code) (425)771-6384
III Send all property tax correspondence to: D Same as Buyer/Grantee List all real and personal property tax parcel account List assessed value(s)
numbers—check box if personal property
Name 962-113-501 p $10,400.00
Mailing Address
City/State/Zip n
Phone No.(including area code) n
Street address of property:
This property is located in Jefferson County
❑Check box if any of the listed parcels are being segregated from a larger parcel.
Legal description of property(if more space is needed,you may attach a separate sheet to each page of the affidavit)
Lots 1 and 2,Block 135,Division 6,lrondale Townsite,as recorded in Volume 2,page 139,records of Jefferson County,State of
Washington.
Situate in the County of Jefferson,State of Washington.
Subject to covenants,conditions,easements,reservations and restrictions of record,if any.
® Select Land Use Code(s): II List all personal property(tangible and intangible)included in selling
191-Undeveloped land(land only) I price.
enter any additional codes: Nnnp
(See back of last page for instructions)
YES NO
Is this property exempt from property tax per chapter ❑ p
84.36 RCW(nonprofit organization)?
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? ❑ 0
Is this property classified as current use(open space,farm and ❑ IJ WAC No. (Section/Subsection) 458-61A-202(1)
agricultural,or timber)land per chapter 8434? Reason for exemption
Is this property receiving special valuation as historical property ❑ 0 Inheritance
per chapter 84.26 RCW?
If any answers are yes,complete as instructed below.
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) Type of Document Personal Representative's Deed.
NEW OWNER(S):To continue the current designation as forest land or
classification as current use(open space,farm and agriculture,or timber) Date of Document 4-114115
land,you must sign on(3)below.The county assessor must then determine Gross Selling Price $ 0.00
if the land transferred continues to qualify and will indicate by signing below.
If the land no longer qualifies or you do not wish to continue the designation *Personal Property (deduct) $ 0.00
or classification,it will be removed and the compensating or additional taxes Exemption Claimed(deduct) $ 0.00
will be due and payable by the seller or transferor at the time of sale.(RCW
84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Taxable Selling Price $ 0.00
your local county assessor for more information. Excise Tax : State $ 0.00
This land ❑does ❑does not qualify for continuance. 0.0050 Local $ 0.00
*Delinquent Interest: State $ 0.00
DEPUTY ASSESSOR DATE Local $ 0.00
(2) NOTICE OF COMPLIANCE(HISTORIC PROPERTY) *Delinquent Penalty $ 0.00
NEW OWNER(S):To continue special valuation as historic property,
sign(3)below.If the new owner(s)does not wish to continue,all Subtotal $ 0.00
additional tax calculated pursuant to chapter 84.26 RCW,shall be due *State Technology Fee $ 5.00
and payable by the seller or transferor at the time of sale.
(3) OWNER(S)SIGNATURE *Affidavit Processing Fee $ 0.00
Total Due $ 10.00
PRINT NAME
A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
® I CERTIF UNDER PENALT OF PERJURY THAT THE FOREGOING IS TRUE AND ORRECT.
Signature of C// Signature of 7
Grantor or Grantor's Agent /% P/S Grantee or Grantee's Agent // l C
Name(print) Kris G.Andersen,Personal Representative Name(print) Kris G.Andersen,Trustee
Date&city of signing: +J/44 1 gim 44,eiS Date&city of signing: If1 fl 1 C✓ i'dN°
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)).
REV 84 0001a(11/19/08) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURI
694115 12:1061 44/24/2015 10.00*
12:2JDC49