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Home My WebLink About123063 • r*?Ilppartmont n( I h d›Ct evenue ci vtiostirvan Stop REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT when stamped by cashier. CHAPTER 82.45 RCW—CHAPTER 458-61 A WAC THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED (See back of last page for instructions) File No,)I0950.IMM 1:1 Check box if partial sale of property If multiple owners,list percentage of ownership next to name 1. Name Marjorie I.Foister,as her separate estate Name Cy W.Thaxton and Ingo D.Thaxton,husband and wife C, Mailing Address 21811 96th Avenue West t i Mailing Address I l l Grover Lane z z 7:1 City/State/Zip Edmonds,WA 98020 City/State/Zip Santa Cruz,CA 95060 Phone No.(including area code) (425)873-3126 L.." Phone No.(including area code) (831)425-8041 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 Cy W.Thaxton and Inga D.Thaxton 502 104 041 0 117,563.00 Mailing Address 111 Grover Lane 0 City/State/Zip Santa Cruz,CA 95060 451 17.3 1 Phone No (including area code) (831)425-8041 0 ® Street address of property: 91 Pleasant Harbor Road,Brinnon,WA 98320 This Property is located in X unincorporated Jefferson County OR within 0 city of Brin non 12 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) Parcel 4 of Cedar Cove Short Plat, as per plat recorded in Volume 1 of Short Plats, page 66, records of Jefferson County, Washington; TOGETHER WITH second class tidelands, as conveyed by the Slate of Washington, adjoining and abutting thereon; EXCEPT Cedar Cove Road. Situate in the County of Jefferson, State of Washington. 5. Select Land Use Code(s): 91 7. List all personal property(tangible and intangible)included in selling price. Enter any additional codes: (Sec back of last page for instructions) Is this property exempt from property tax per YES NO chapter 84.36 RCW(nonprofit organization)? 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: 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 It'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 21,2015 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 duality and will indicate by signing below. Gross Selling Price S 85,000.00 If the land no longer qualities or you do not wish to continue the designation *personal Property(deduct) S or classification,it will he removed and the compensating or additional taxes will he 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 85,000.00 Excise Tax: State S 1,088.00 This land [1]does 0 does not qualify for continuance Local S 425.00 *Delinquent Interest: State S Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty S (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal S 1,513.00 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 1,518.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS UI CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT Signature of Signature of Grantor or Grantor's Agent RAJ cP/1044) Grantee or Grantee's Agent Name(print) ,i/rrtasii#1■4 th.chx.k crNa.r.c.‘y Name(print) ('y W.Tbaxton Date&city of signing: 'N\-4,1.k■S 7.4.rn.011AS 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 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 694140 123067 *4/24/2015 1 ,518.00* 1 V2J Otki eortmeru of ` l evenue N.IfiM�[rx1 kevr REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT when stamped by cashier. CHAPTER 82,45 RCW—CHAPTER 458-6IA WAC THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED (See back of last page for instructions) File No.80950JMM ❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name 1. Name Mariorie I.Foister,as her separate estate Name CY W.Thaxton and Inca D.Thaxton,husband and wife HMailing Address 21811 96th Avenue West w Mailing Address 111 Grover Lane z a City/State/Zip Edmonds,WA 98020 City/State/Zip Santa Cruz,CA 95060 G Phone No.(including area code) (425)873-3126 Phone No.(including area code) J831)425-8041 3. Send all property tax correspondence to:❑Same as Buyer/Grantee List all real and personal tax parcel account Listed assessed value(s) numbers—cheek box if personal property Name Cy W.Thaxton and Inga D.Thaxton 502 104 041 ❑ 117,563.00 Mailing Address I I I Grover Lane ❑ City/State/Zip Santa Cruz,CA 95060 ( J i I ❑ Phone No.(including area code) (831)425-8041 l f ❑ En Street address of property: 91 Pleasant Harbor Road,Brinnon,WA 98320 This Property is located in X unincorporated Jefferson County OR within❑city ofBrinnon ❑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) Parcel 4 of Cedar Cove Short Plat,as per plat recorded in Volume I of Short Plats,page 66,records of Jefferson County, Washington; TOGETHER WITH second class tidelands,as conveyed by the State of Washington,adjoining and abutting thereon; EXCEPT Cedar Cove Road. Situate in the County ofJefferson, State of Washington. 5. Select Land Use Code(s): 91 7. List all personal property(tangible 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)? ❑ 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? ❑ 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 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 21,2015 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 85,000.00 If the land no longer qualifies or you do not wish to continue the designation *Persona) Property(deduct) $ 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 85,000.00 This land does Excise Tax: State S 1,088.00 ❑ ❑does not qualify for continuance Local S 425.00 *Delinquent Interest: State S Local S DEPUTY ASSESSOR DATE *Delinquent Penalty S (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal S 1,513.00 NEW OWNER(S): To continue special valuation as historic property, sign(3)below. ifthe new owner(s)do 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 S (3) OWNER(S)SIGNATURE Total Due $ 1,518.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS i CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT Signature of Signature of Grantor or Grantor's Agent Grantee or Grantee's Agent Name(print) Marjorie I.Foister Name(print) Cy W.Thaxton i - Date&city of signing: Date&city of signing / `L'rfrrt>$i. 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(55,000.00),or by both imprisonment and fine(RCW 9A.20.020(IC). REV 840001a(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER