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Home My WebLink About123062 • N , (At?Department nf evenue qd-9 7 I Stae PLEASE TYPE OR PRINT REAL ESTATE EXCISE TAX AFFIDAVIT . This form is your receipt when by cashier. CHAPTER 82.45 RCW-CHAPTER 458-61A WAC stamped THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED (See back of last page for instructions) File No.80871.1MM Check box if partial sale of property If multiple owners,list percentage of ownership next to name 1. Name Keith Rex and Donna Rex,husband and wife Name David A.Nicewonger,a single man and Deborah J. Leander,a single woman Mailing Address 20220 Beach Dr. Mailing Address 5909 Panorama Dr.SE#18-101 al f- t :L Z City/State/Zip Stanwood,WA 08292 — City/State/Zip Auburn,WA 98092 ce Phone No.(including area code) (360)654-0606 C, Phone No.(including area code) (253)310-1068 3. Send all property tax correspondence to:1:3 Same as Buyer/Grantee List all real and personal tax parcel account Listed assessed value(s) numbers-check box if personal property 123,905.00 Name David A.Nicewonger and Deborah J.Leander 701 314 020 Mailing Address 5909 Panorama Dr.SE#18-10I CZ El City/State/Zip Auburn,WA 98092 Phone No.(including area code) (253)310-1068 1\040eP VI Street address of property: Vacant Land On E.Quilcene Rd.,Quilcene,WA 98376 This Property is located in 0 unincorporated Jefferson County OR within X city of Quilcene 0 Check box if any of the listed parcels are being segregated from a larger parcel,are part of 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) SEE EXHIBIT"A"ATTACHED HERETO AND MADE A PART HEREOF FOR COMPLETE LEGAL DESCRIPTION 1311 Select Land Use Code(s): NEE List all personal property(tfmgible and intangible)included in selling price. Enter any additional codes: (See hack of last page for instructions) Is this property exempt from property tax per YES NO chapter 84.36 RCW(nonprofit organization)? 0 X b. YES NO Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption: RCW? 0 X Is this property classified as current use(open space,farm and x agricultural,or timber)land per chapter 84.34? WAC No.(Section/Subsection) Is this property receiving special valuation as historical 0 X property per chapter 84.26 RCW,' Reason for exemption - If any answers arc yes,complete as instructed below. Type of Document Statutory Warrants Deed (I)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) NEW OWNER(S): To continue the current designation as forest land or Date of Document April 21,2015 classification as current use (open space, farm and agriculture, or timber) land.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. Gross Selling Price S 155,000.00 If the land no longer qualifies or you do not wish to continue the designation *Personal Property(deduct) S or classification,it will be removed and the compensating or additional taxes will be due and payable by the seller or transferor at the time of sale. (RCW Exemption Claimed(deduct) S No 84.33.140 or RCW 84.34.108). Prior to signing(3)below,you may contact your local county assessor for more information. Taxable Selling Price S 155,000.00 Excise Tax: State S 1,984.00 This land 0 does 0 does not qualify for continuance Local S 775.00 *Delinquent Interest: State S Local S DEPUTY ASSESSOR DA'EE *Delinquent Penalty S (2)NOTICE OF COMPLIANCE.(HISTORIC PROPERTY) NEW OWNER(S): To continue special valuation as historic property, Subtotal S 2,759.00 sign(3)below. If the new owner(s)do not wish to continue,all *State Technology Fee S 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 S (3) OWNER(S)SIGNATURE Total Due S 2,764.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS 1111 I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT Signature of Signature of Grantor or Grantor's Agent ....OW _/ Grantee or Grantee's Agent Name(print) Keith Rex Name(print) David A.Nicewonger Date&city of Date&city of signing 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 titan five thousand dollars($5,000.00),or by both imprisonment and fine(RCW 9A.20.020(1C). REV 84 0001 a(04/30/09) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER tc 694136 123062 *4/24/2015 2,764.00* Difia (POflerArtment sI evenue NOsixrcw,Stdt PLEASE TYPE OR PRINT REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt when by cashier. CHAPTER 82,45 RCW—CHAPTER 458-61A WAC stamped THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED (See back of last page for instructions) File No,80871,1MM 0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name 1. Name Keith Rex and Donna Rex,husband and wife Name David A.Nicewonger,a single man and Deborah J. Leander,a single woman C Mailing Address 20220 Beach Dr. c4 it' Mailing Address 5909 Panorama Dr.SE#18-101 z z 7,1 City/State/Zip Stanwood,WA 98292 < City/State/Zip Auburn,WA 98092 Phone No.(including area code) (360)654-4)606 c, Phone No.(including area code) j253)310-1068 3. Send all property tax correspondence to:0 Same as Buyer/Grantee List all real and personal tax parcel account Listed assessed value(s) numbers—check box if personal property Name David A.Nicewonger and Deborah J.Leander 701 314 020 123,905.00 Mailing Address 5909 Panorama Dr.SE#18-101 0 City/State/Zip Auburn,WA 98092 0 Phone No. including area code) (253)310-1068 1755 0 Street address of property: Vacant Land On E.Quilcene Rd.,Quileene,WA 98376 This Property is located in 0 unincorporated Jefferson County OR within X city of Quileene 0 Check box if any of the listed parcels are being segregated from a larger parcel,are part of 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) SEE EXHIBIT"A"ATTACHED HERETO AND MADE A PART HEREOF FOR COMPLETE LEGAL DESCRIPTION En Select Land Use Cade(s): Es List all personal property(tangible and intangible)included in selling price. Enter any additional codes: (See back of last page for instructions) Is this property exempt from property tax per YES NO chapter 84.36 RCW(nonprofit organization)? 0 X 6. YES NO Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption: RCW? 0 X Is this property classified as current use(open space,farm and Ei x agricultural,or timber)land per chapter 84.34? WAC No.(Section/Subsection) Is this property receiving special valuation as historical 0 X property per chapter 84.26 RCW? Reason for exemption If any answers are yes,complete as instructed below. Type of Document Statutory Warranty Deed (I)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) NEW OWNER(S): To continue the current designation as forest land or Date of Document April 21,2 01 5 classification as current use (open space, farm and agriculture, or timber) land,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. Gross Selling Price S 155,000.00 If the land no longer qualifies or you do not wish to continue the designation *Personal Property(deduct) S or classification,it will be removed and the cotnpensating or additional taxes will be due and payable by the seller or transferor at the time of sale. (RCW Exemption Claimed(deduct) S No 84.33.141)or RCW 84.34.108) Prior to signing(3)below,you may contact i 55 your local county assessor for more inforniation. Taxable Selling Price S 1 .000.00 Excise Tax: State S 1,984.00 This land 0 does 0 does not qualify for continuance Local S 775.00 *Delinquent'Interest: State S Local S DEPUTY ASSESSOR DATE *Delinquent Penalty S (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal S 2,759.00 NEW OWNER(S): To continue special valuation as historic property, sign(3)below. If the new owner(s)do not wish to continue,all *State Technology Fee S 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 S (3) OWNER(S)SIGNATURE Total Due S 2,764.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS 111 I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT Signature of Signature of Grantor or Grantor's Agent Grantee or Grantee's Agent Name(print) Keith Rex Name(print) David A.Nicewonger Date&city of signing: Date&city of signing A 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(IC). REV 84 0001a(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER • EXHIBIT A Parcel 6A of Survey recorded March 4. |908, under Auditor's File No. 3i3306, bo Volume Yn[Surveys, page 8j; being a portion of Government Lots 2 and 3, Section 31, Township 27 North, Range I West,W.M., in Jefferson County. Washington. EXCEPTING THEREFROM right-of-way for East Quilcene County Road, as conveyed to Jefferson County, by deed recorded December 18` 1940, under Auditor's File No. 92611, records of Jefferson County, Washington; TOGETHER WITH that portion of Second Class Tidelands suitable for the cultivation of oysters adjoining Government Lot 2, Section 3 1, Township 27 North, Range I West, W.M., Jefferson County, Washington, as conveyed by the State of Washington in instrument recorded in Volume 54 of Deeds, page 172, being more particularly described as follows: Beginning at the Southwest corner of Lot 6A of Survey as recorded under Volume 9 of Surveys, page 63, records of Jefferson County. Washington; thence South 88»55`39'` West along the extension of the South line of said LotôA for a distance of 166.14 feet; thence North 5"|}"37'` East 257.0jfeet; thence East 162.99 feet; � , thence South 4"55"37^West 253.67 feet tv the Point ofBeginning. Situate in the County of Jefferson.State of Washington.