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Department of "'
Revenue y~ �� �
Washington State REAL ESTATE EXCISE TAX AFFIDAVIT
CHAPTER 82.45 RCW-CHAPTER 458-61A WAC This form is your receipt
PLEASE TYPE OR PRINT 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.
Fannie Mae aka Federal National Mortgage 2 Patrick E. Moore and Pamela Moore, husband
_ Name Association, organi**See Exhibit A for Full Names — Name and wife
14221 Dallas Parkway Suite 1000, Mailing Address 4494 San Juan Avenue
OF Mailing Address L140B7H "'
Z } City/State/Zip Port Townsend,WA 98368
LLI.1 City/State/Zip Dallas, TX 75254
u)0
°o 0 Phone No,(including area code)
Phone No.(including area code)
List all real and personal property tax parcel
3 Send all property tax correspondence to: RI Same as Buyer/Grantee account numbers-check box If personal property List assessed value(s)
Name 992300043 ❑ $193,662.00
Mailing Address '', y 1 g 24 ❑
City/State/Zip ❑
Phone No.(including area code) ❑
4 Street address of property: 4494 San Juan Avenue, Port Townsend, WA 98368
The property is located in❑unincorporated County OR within m city of Port Townsend
❑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 43, San Juan Estates, as per Plat recorded in Volume 6 of Plats, Pages 35 and 36, records of Jefferson
County, Washington.
Situate in the County of Jefferson, State of Washington.
5 Select Land Use Code(s): 1 1 1 7 List all personal property(tangible and intangible)included in selling price.
Enter any additional codes:
(See back of last page for instructions)
YES NO
Was the seller receiving a property tax exemption or deferral under ❑ Er
chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior
citizen,or disabled person,homeowner with limited income)?
6 I YES NO
Is this property designated as forest land per chapter 84.33 RCW? ❑ If claiming an exemption,list WAC number and reason for exemption:
Is this property classified as current use (open space, farm and
❑ Ezi
agricultural,or timber)land per chapter 84.34 RCW? WAC No.(Section/Subsection) 458-61A-205(2)
Is this property receiving special valuation as historical property per ❑ El Reason for exemption Government transfer
chapter 84.26 RCW?
If any answers are yes,complete as instructed below.
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE)
NEW OWNER(S): To continue the current designation as forest land or Type of Document Bargain and Sale Deed
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 Date of Document 04/21/2015
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 or classification,it will Gross Selling Price $ 189,500.00
be removed and the compensating or additional taxes will be due and payable by the *Personal Property(deduct)$ 0.00
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 your local county assessor for more Exemption Claimed(deduct) $ 189,500.00
information.
Taxable Selling Price $ 0.00
Excise Tax: State $
This land❑does❑does not qualify for continuance. Local $
*Delinquent Interest: State $
DEPUTY ASSESSOR DATE
Local $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) *Delinquent Penalty$
NEW OWNER(S): To continue special valuation as historic property, sign (3)
below. If the new owner(s)does not wish to continue,all additional tax calculated Subtotal $
pursuant to Chapter 84.26 RCW,shall be due and payable by the seller or transferor *State Technology Fee $ 5.00
at the time of sale. 9Y
(3)OWNER(S)SIGNATURE *Affidavit Processing Fee $ 5.00
Total Due $ 10.00
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
8 I CERTIFY UNDER PE •L OF PER URY THAT THE FOREGOING IS TRUE ' D CORRECT.
Signature of Signature of
Agent LA2' 'J „ �- °, 4�' Grantee or Grantee's 4r „/
Teres- Barnes, Chicago Title Company of Teresa Varnes, Chicago Title Company of
Name(print)Washington Name(print) Washington
Date&city of signing April 21, 2015 Everett Date&city of signing April 21, 2015 Everett
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(6/26/14) THIS SPACE-TREASURER'S USE ONLY ❑County Treasurer
❑County Assessor
Escrow No.: 500025248-TV ❑Dept.of Revenue
❑Taxpayer
n 4_
e;94147 4 127,00;4 *4/''24,/2015 10.00*
1 z o -}
EXHIBIT"A"
Seller/Grantor Full Name: Fannie Mae aka Federal National Mortgage Association,organized and existing under the
laws of the United States of America,P.O.Box 650043,Dallas TX 75265-0043
Real Estate Excise Tax Affidavit-Exhibit Page Printed:04.21.15 @ 03:49 PM by TV
WA00000839.doc/Updated: 10.10.14 WA-CT-FNRV-02150.624693-500025248