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HomeMy WebLinkAbout125228 02 \CO Department of \frek ' Revenue Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT CHAPTER 82.45 RCW—CHAPTER 458-61 A 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.artial sale of.rode ,,� /I1��I I m Iti.le owners list.ercenta•-of owners i.next to name. I Name l"A L+ ki I____ �i.. 2 Na r f� 5/I rte— /L.l.?!.............11... . '/ W dZe r. W, Htm. „ ,,, � zz� Mailing Address ''Pt� 1 t' (, 4-1._ AD, L4 p �w.F- Mailing Address 7 `� 1..r.J t '.`� 411 (2.. City/State/Zip C N/m C / WA j D �j� �m City/State/Zip Q1 /� / 7 ry,WC{ / •) Phone No.(including area code) 31:30--73, -q 35( Phone No.(including area code).63 Cf2 ) ,J c '1 `5 61 ® Send all roe tax correspondence to: List all real and personal property tax parcel account property rty p ❑Same as Buyer/Grantee List assessed value(s) ��� ✓ e GU , ` U n� numbers—check box if personal property Name (/t/ �V// • f• ❑ k� el Mailing Address �� V.f,- �� _ D f 'y 7 Q©� v I� City/State/Zip CM ZrneLC 1I.4'! rte-- 2g b� .arc qo / 00 - - 4 Phone No.(including area code) 7 3� 300� 1"I \ �I� 4 _ aa,301 L UStreet address of property: This property is located in Jefferson County 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 property(if more space is needed,you may attach a separate sheet to each page of the affidavit) See \Ao,.<Ve Select Land Use Code(s): /� IN List all personal property(tangible and intangible)included in selling 111 Select Land Use Codes -� 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 84.38 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? 6 If claiming an exemption, list WAC number and reason for exemption: YES NO Is this property designated as forest land per chapter 84.33RC'W? 0 0WAC No. (Section/Subsection) ' 65-1 47/A " a Q3 d Is this property classified as current use(open space, aand ❑ 0 Reason for exemption 79 ( 1" C��� ...- agricultural,or timber)land per chapter 84.34 RC1'. l' / Is this property receiving special valuation as historical property 0 0 � �� per chapter 84.26 RC W? If any answers are yes,complete as instructed below. Type of Document Q CD (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) - Z Z NEW OWNER(S):To continue the current designation as forest land or Date of Document / 6 classification as current use(open space,farm and agriculture,or timber)land, Gross Selling Price $ 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.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 $ 0.00 84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Excise Tax : State $ 0.00 your local county sensor for more information. I 0.0050 Local $ 0.00 ThisJ2nd does ❑dines)not , I'fy for //c,.onnttiinuant .}� j *Delinquent Interest: State $ e -�-e /����'�//—till 7? Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) 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 It C. shall be due and K BO *Affidavit by the seller or transferor at the time of sale. Processing Fee $ (3) OWNER(S)SIGNATURE r Total Due $ 10.00 ale , /� y �. �/ } ; i.1i3.bY��2.+ . �` .Lt / PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX c.f ,mit tkirfra © *SEE INSTRUCTIONS I//CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of k * Grantor ori A ent /4/4. 10 nature of tee' `' / g or Grantee s Agent Name(print) ,h Rte// Al ,it,,,,d/ __ av/ printG N/1/4) I t , Date&city of signing: , ... _/ . Date&city of signing: ' — 1 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(1 C)). REV 84 0001a(01/04/16) THIS SPACE-TREASURER'S USE ONLY j COUNTY TREASURER Y ( X i 741941 125228 4:4/22/2016 10.00* I?A22e The Southwest of the Southwest , the Southeast of the Southwest and the Southwest of the Southeast of Section 4, Township 29 North, Range 1 West of the Willamette Meridian, EXCEPTING FROM the Southwest of the Southeast of said Section 34, the following described tract, to-wit: Beginning at the intersection of the two County Roads in the Southeast corner of the Southwest of the Southeast of said Section 34, said roads known as the "Egg & I" road, and the Center to Chimacum, road thence North along the Center to Chimacum County Road , 248 feet ; thence West, at right angles, 342 feet ; thence South at right angles, 300 feet to intersect the North line of said j -: .`F "Egg & I" County Road; thence East, along the North lime of sand "Egg & I" County Road , 454 feet to the place of beginning for this excepted tract. a c�c�j 0