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HomeMy WebLinkAbout123081 � _ t Department of Revenue REAL ESTATE EXCISE SE TAX AFFIDAVIT IT Washington State CHAPTER 82.45 ROW-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) 0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name, 1 I Michael A. Mongiello, Jr. and Aida T. Mongiello, 2 Michael G. Burke and Barbara E. Burke, husband 1 Name Trustees of`"See Exhibit A for Full Names ,a,,,e and wife a erI Mailing Address 82 Timber Heights Dr — z , Mailing Address 82 Timber Heights Dr WI-i iw a: City/State/Zip Port Ludlow,WA 98365 cicyistaterzip Port Ludlow, WA 98365 Phone No (including area code) I "; Phone No.(including area code) 3 List all real and personal property tax parcel { Send all property tax correspondence to: El as f3uyer.'Granlee account numbers•check box II personal property 1 List assessed value(s) i Name 998500072 0 $434,840.00 Mailing Address Levy..Code: 0231 ❑ • city/state/zip _-...... )'�1D r 4'J3 75___._ . _,D Phone No.(including area code) Q L.A.i Street address of property: 82 Timber Heights Dr, Port Ludlow, WA 98365 The property is located in 0 unincorporated County OR within©city of Port Ludlow 0 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 properly(if more space is needed.you may attach;+separate sheet to each page of the affidavit) Lot 72, Timberton Village Phase III, as per Plat recorded in Volume 7 of Plats, pages 144 through 149, records of Jefferson County, Washington. Situate in the County of Jefferson, State of Washington. i 5 I Select Land Use Code(s): �1.... _.....-_.___._._._._._....._.-._ .. _.__— '? List all personal property(tangible and intangible)included in selling price. Enter any additional codes: (See back of last page for instructions) YES NO i Was the seller receiving a property tax exemption or deferral under © © chapters 84.36, 84.37. or 84.38. ROW (nonprofit organization, senior citizen. or disabled person, homeowner with limited income)? 6 i YES NO Is this property designated as forest(and per chapter 84.33 RCW? 0 © ' If claiming an exemption,li WA-0 number and reason far exemption; is this property classified as current use (open space, farm and © agricultural,or timber)land per chapter 84.34 RCW? WAC No (SectioniSubsection) Is this r p openly receiving special valuation as historical property per chapter 84.26 RCW? © Reason for exemption, 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 Tvae of Document Statutory.Warranty Deed classification as current use(open space.farm and agriculture.or limber)land,you y ----- ...Y 14 ht-.6 - must sign on (3)below, The county assessor must then determine if the land Dale of Document 1-5 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 cr classification,it Gross Selling Price $ 525,000.00 will be removed and the compensating or additional taxes will be due and payable by the seller or transferor at the time of sale. (ROW 84,33.140 or ROW 84.34,108). , 'Personal Property(deduct) $ 0-00 Prior to signing(3)below, you may contact your local county assessor for;tire information. Exemption Claimed(deduct) $ 0.00 • Taxable Selling Price $ 525,000.00 Excise Tax: State $ 6,720_00 This land 0 does 0 does not quality for continuance. Local $ 2,625.00 'Delinquent Interest: State$ 0.00 DEPUTY ASSESSOR DATE — —__.__......___....__. Local $ 0,00 (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Delinquent Penalty $ 0.00 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 $ 9,345.00 pursuant to Chapter 84.26 RCW, shall be due and payable by the seller or _ transferor at the time of sate. Slate Technology Fee $ 5.00 "Affidavit Processing Fee $ 0,00 (3)OWNERS)SIGNATURE Total Due $ 9.350.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX ..._.._..__.__.,._..,_� s 'SEE INSTRUCTIONS I._$J I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of Signature of Grantor or Grantor's Agen •� i).J..tLJ- Grantee or Grantee's e�lt _ Christy Bunich,Fidelity National Title Company of Name(print) Michael A. Mongiello, Jr_ Name(print) Washington Date&city of s gnieg T,21-aces Po et ),u cif kc,) to A I Date 8 city of signing April 17 2015 Mercer Island Perjury: Perjury is a class C felony which is punishable by imprisonment ill the state correctional institution for a maximum term of not more than live years,or by a fine in an amount fixed by the court of not more than five thousand dollars($5.e00 00),or by both imprisonment and fine(ROW 9A.30.020(10)1. REV 84 0001a(6126/14) THIS SPACE-TREASURER'S USE ONLY ❑County Treasurer 0 County Assessor Escrow No.: 611094058-CE ❑Dept.of Revenue C Taxpayer 700401 1270R1 *4/29/2015 9,350.00* //•/� 1 Vhf» EXHIBIT "A" Seller/Grantor Full Name: Michael A. Mongiello,Jr. and Aida T. Mongiello, Trustees of the Mongiello Family Revocable Living Trust dated February 19, 2009 Real Estate Excis Tax Affidav4Ethibtl Page Printed: 04 17 15 vwu00oomw.doc/Updated: 1um.w WA-FT.FTMA-01530.610019-6'11094058