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Department of K5?
Revenue • ` `1
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)
n Check box if partial sale of property If multiple owners,list percentage of ownership next to name.
Name David A.Goetze,a single man and EJM,LLC.a Washingion 1:117 fl Name EJM,LLC.A Washington Limited Liability Company
t i/r 1 5
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w O PO BOX 1994 / 'f{P 1ujY1/J��L11 736 Calhoun Street
Mailing Address '/ Mailing Address
City/State/Zip Port Townsend,Wa.98368 City/State/Zip Port Townsend,Wa 98368
tY P
Phone No.(including area code) 360-531-4488 Phone No.(including area code)360-385-6602
® Send all property tax correspondence to:0 Same as Buyer/Grantee List all real and personal property tax parcel account List assessed value(s)
numbers—check box if personal property
Name 701-184-006 ❑ $163,720.00
Mailing Address -T-1.04- ❑
City/state/Zip ❑
Phone No.(including area code) ❑ MiaP Y°
Street address of property: 1130 East Quilcene Street
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)
See Exhibit"A"
Abbrev.Legal PTN GL3 18-27-1 W
Select Land Use Code(s): ®List all personal property(tangible and intangible)included in selling
Jii-Household,single family units j 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 0 0
chapters 84.36,84.37,or 8438 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 84.33RCW? 0 0 WAC No.(SectiontSubsection)
Is this property classified as current use(open space,fann and 0 0
agricultural,or timber)land per chapter 84.34? Reason for exemption
Is this property receiving special valuation as historical property 0 O
per chapter 84.26 RCW?
If any answers are yes,complete as instructed below. Type of Document QCD
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE)
NEW OWNER(S):To continue the current'designation as forest land or
Date of Document 4/27/2015
classification as current use(open space,farm and agriculture,or timber)land, 82,500.00
you must sign on(3)below.The county assessor must then determine if the Gross Selling Price $
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 Exemption Claimed(deduct) $
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 Taxable Selling Price $ ,5045 '' 0.00
84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Excise Tax:State $ 705-‘,C70 0.00
your local county assessor for more information. 0.0000 Local $ /• •Jam() 0.00
This land adoes 0 does not qualify for continuance. *Delinquent Interest: State $
Local $
DEPUTY ASSESSOR DATE
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) *Delinquent Penalty $
NEW OWNER(S):To continue special valuation as historic property, Subtotal $ 0.00
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 $
(3) OWNER(S)SIGNATURE Total Due $ /Y"73. 50, 10.00
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 J
Grantor or Grantor's Agent Grantee or Grantee's Agent �. /•�. �J. �i $ ,` • Am
Name(print)Z�QU cm J�A. Cp D ET Z tl~ Name(print)'SWt LL"L E I RA-13 h4L T ( I UrL/f y(! i
Date&city of signing: 4/27/2015 Port Townsend,Wa Date&ci of signing-
Perjury: 4/27/2015
city gning:
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(6/5/13) THIS SPACE—TREASURER'S USE ONLY TAXPAYER
6'?'?�� _2 123071 :C4/28/2015 1 ,473.50*is#:
EXHIBIT A
That portion of Government Lot 3 in Sections 18, Township 27 North, Range 1 West, W.M.,
described as follows:
Beginning at the meander corner on the East shore of Quilcene Bay on the line between Section 18
and 19, Township 27 North, Range 1 West, W.M., and running thence East 18 feet;
thence North 61 1/2° East 273 feet to center of road;
thence along the center of said road, North 38° West 1,007 feet;
thence South 52° West 10 feet to the initial point of this description;
thence South 52° West 396 feet to the meander line;
thence with the meander line North 40 ''/2° West 115 feet;
thence North 52° East 400 feet to a point 10 feet from the center of road;
thence South 38° East 115 feet, more or less, to the Place of Beginning;
EXCEPTING THEREFROM the right-of-way of the county road; AND EXCEPT that portion
thereof, if any, lying within tidelands of the second class.
Situate in the County of Jefferson, State of Washington.
1. Easement and the terms and conditions thereof:
Disclosed by: Book 3 of Mining Records, page 433
Purpose: For a flume and ditch for irrigation and domestic water
Affects: Portion of said premises and other property
2. Right of the State of Washington in and to that portion, if any, of the property herein
described which lies below the line of ordinary high water of the Quilcene Bay.
3. Rights of the general public to the unrestricted use of all the waters of a navigable body of
water not only for the primary purpose of navigation, but also for corollary purposes;
including (but not limited to) fishing, boating, bathing, swimming, water skiing and other
related recreational purposes, as those waters may affect the tidelands, shorelands or
adjoining uplands and whether the level of the water has been raised naturally or artificially to
a maintained or fluctuating level, all as further defined by the decisional law of the state.
(Affects all of the premises subject to such submergence)
4. Any loss or damage, because Jefferson County, Washington or the State of Washington
chooses to not accept the amount of excise tax tendered or chooses to record a lien against the
property because the correct amount of excise tax was not paid at the time of the sale.
LPB 10.05(1-1)
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