HomeMy WebLinkAbout123084 Department of :3 `:a
Revenue
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)
❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name.
flName Poulsbo Investments, LLC ill Name Robert H. Tozer. Jr.
x
a z Mailing Address 6314 SR 22nd Ste. 123
H Mailing Address 4992 Paradise Bay Rd.
city/state/zip Mercer Island. WA 98040 m city/state/zip Port I udow WA 98385
Phone No.(including area code) Phone No.(including area code)
• List all real and personal property tax parcel account
Send all property tax correspondence to:®Same as Buyer/Grantee List assessed value(s)
numbers-check box if personal property
Name 821-351-033 n 3 0l 07 (
Mailing Address n
City/State/Zip n
Phone No.(including area code) n
® Street address of property: 4992 Paradise Bay Rd Port I udow WA 98365
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)
Lot 3 Paradise Bay Road-Port Ludlow,WA
Lot 3 of the No.Cents Short Plat,as per Plat recorded in Volume 5 of Short Plats,Pages 28 and 29,Recorded of Jefferson County
Washington.
® Select Land Use Code(s): II List all personal property(tangible and intangible)included in selling
I11-Household,single family units I 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 ❑ p
chapters 84.36,84.37,or 84.38 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 84.33 RCW? ❑ p WAC No. (Section/Subsection)
Is this property classified as current use(open space,farm and ❑
agricultural,or timber)land per chapter 84.34? Reason for exemption
Is this property receiving special valuation as historical property ❑ 12
per chapter 84.26 RCW?
If any answers are yes,complete as instructed below.
Type of Document Contract Deed
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE)
NEW OWNER(S):To continue the current designation as forest land or Date of Document 4/1/15
classification as current use(open space,farm and agriculture,or timber)land, 422,000.00
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 $ 422,000.00
84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Excise Tax : State $ 5,401.60
your local county assessor for more information. 0.0050 Local $ 2,110.00
This land Eldoes El does not qualify for continuance. *Delinquent Interest: State $
Local $
DEPUTY ASSESSOR DATE *Delinquent Penalty $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) 7,511.60
NEW OWNER(S):To continue special valuation as historic property, Subtotal $
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 $ 7,516.60
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
I CERTIFY NDER PENALT OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Signature of
Grantor or Grantor's Agent te►/ — Grantee or Grantee's Ag���y�i
Name(print) 44' IG� /4.. Name(print) --I-2a
Date&city of signing: V2-pci/5 5749 Date&city of signing: L/-2$---2sw /a
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(02/19/15) THIS SPACE-TREASURER'S USE ONLY COUNTY ASSESSOR VQ1 y r20 5 ;_
7_-� ! 1'73084 j
2:2-,0 gc-f