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Home My WebLink About123079 °venue `� 35"r REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT when stamped by cashier. CHAPTER 82.45 RCW—CHAPTER 458-61A WAC THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED (See back of last page for instructions) File No.57061RW ❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name i. Name Ruth D.Seaberg,as her separate estate Name William P.Black and Susan T.Black,husband and wife w O Mailing Address 23600 Marine View Dr S,Apt 447 W F Mailing Address P.O.Box 134 City/State/Zip Des Moines,WA 98198 m z City/State/Zip Block Island,RI 02807 CD Phone No.(including area code) 360-437-2278 Phone No.(including area code) 603-677-2357 ;. Send all property tax correspondence to:El Same as Buyer/Grantee List all real and personal tax parcel account Listed assessed value(s) numbers-check box if personal property Name William P.Black 961 601 502 ❑ 199,198.00 Mailing Address P.O.Box 134 ❑ City/State/Zip Block Island,RI 02807 ❑ Phone No.(including area code) ❑ Street address of property: 41A S Keel Way,Port Ludlow,WA 98365 This Property is located in❑unincorporated Jefferson County OR within®city of Port Ludlow ❑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 ® Select Land Use Code(s): 14 Ea List all ersonal p 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)? ❑ IZI ® YES NO Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption: RCW? ❑ El Is this property classified as current use(open space,farm and ❑ agricultural,or timber)land per chapter 84.34? WAC No (Section/Subsection) Is this property receiving special valuation as historical property per chapter 84.26 RCW? ❑ ® Reason for exemption If any answers are yes,complete as instructed below. Type of Document Statutory Warranty Deed (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) S3 ti NEW OWNER(S): To continue the current designation as forest land or Date of Document Aprih'!Q,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 $ 208000.00 If the land no longer qualifies or you do not wish to continue the designation *Personal 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) $ 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 $ 208,000.00 This land ❑does ❑does not qualify for continuance Excise Tax: State $ 2,662.40 Local $ 1,040.00 *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) NEW OWNER(S): To continue special valuation as historic property, Subtotal $ 3,702.40 sign(3)below. If the 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 $ (3) OWNER(S)SIGNATURE Total Due $ 3,707.40 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 �9 p/ Grantee or Grantee's Agent Name(print) Ruth D.Seaber, 7lame(print) William P. '1+ck Date&ci ofsi m - tY signing: 4thri �p/S DE5 O4t/c , te,-4 Date&city of signing 4/fimol ok% j tawn 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(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER -7000 .? iy3079 3:4 9.;' j1c 7:5707.40* p1 EXHIBIT A Apartment No. 15A, Building 15, of Inner Harbor Village, a condominium intended for residential use, according to the Condominium Plan and Survey Map delineating said apartment, recorded in Volume 1 of Condominiums, pages 156 through 160; pages 161 through 166; 167 through 171; 172 through 177; 202 through 206; 224 through 228; 229 through 234; 235 through 241; 248 through 254; 261 through 266; and Volume 2 of Condominiums, pages 1 through 7 and 10 through 16; under Jefferson County Recording Nos. 329056; 329608; 330741; 330742; 337633; 340777; 340906; 340907; 342342; 345601; 353091; 355008; located in Port Ludlow; TOGETHER WITH an undivided 2.174% interest in the common areas and facilities appertaining to said apartment, and including therein limited common areas and facilities so appertaining, according to the Condominium Declarations recorded under Jefferson County Recording No. 329057; Said Declaration and Plans are modified or amended by documents recorded under Jefferson County Recording Nos. 329607, 329608, 330741,330742, 337633, 337634, 338754, 340777, 340906, 340907, 342341, 342342, 345600, 345601, 353061, 353062, 355007 and 355008; SUBJECT, however,to possible partial defeasance of this undivided interest, upon inclusion of the subsequent phase(s)to the condominium by recorded amendment to the Declaration; AND TOGETHER WITH that portion of the declarant's interest in the common areas and facilities of the property in any subsequently added phase(s), all as expressly provided for in the declaration, upon properly recorded amendments thereto. Situate in the County of Jefferson, State of Washington.