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HomeMy WebLinkAbout125229 „ ��1iq Department ofrea /..i i,_ Revenue \,�''' A Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your r-cerpt PLEASE TYPE OR PRINT CHAPTER 32.45 ItC'W—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) ❑ e k box if partial sale of proper ' / /j If multiple owners,list percentage of ownersh•.nex,to name. /II Name � ”/mss- - + L� / ...r. "66'' © Name _ ....1a.' ! A. 'A..✓1 • ' /..et. ' / / ie_f 0 .' /1\"` �- %1 r % /' w zzd Mailing Address y 1✓ q ..1 . d z Mailing Address l� C G �), , 0 City/State/Zip C-. CL: "�[,f�G Z r �C.; oa Ic4 City/State/Zip CAI Y►/Lr°C t'J �/ �j°t 7 5'3;2 Phone No.(including are ? 1I A "7-'1 5 i 9 6 J� Phone No.(including area code) ' -3 ‘20-73; 9 ' .5 I © Send all roe tax correspondence to: List all real and personal property tax parcel account property rty p ❑❑Same as Buyer/Grantee numbers-check box if personal property List assessed value(s) Name 6�I e 111]w ht1/ [�/ /kJ 7 ❑ Mailing Address /ck 1.1 (r� t .. g 0/i�j <7100��C�t.�C City/State/Zip G �0'.d� r ' L./ ula— `. / ' Phone No.(including area code) �//o 7 3A` 3`I/"i 80 / rV / At ,,T 07 © Street 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) SQ._ \'( '\AX-.6.'N 4ii Select Land Use Code(s): 1/1 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 ❑ ❑ 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 exemptio YES NO /� Is this property designated as forest land per chapter 84.33 RCW? ❑ p WAC No. (Section/Subsection) g—)5Q 6IA" -- 243 1 Is this property classified as current use(open space farm and 0 Illct Reason for exemption / e Cr ' .2-le06 ,11*b.-NA agricultural,or timber)land per chapter 84,34 RCW? y Is this property receiving special valuation as historical property 0 El r Ds +f�+��N+� ✓ per chapter 84.26 RC GV? / If any answers are yes,complete as instructed below. Type of Document �.`�CO (1)NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) fi NEW OWNER(S):To continue the current designation as forest land or Date of Document . 2.2- / cf' 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 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 $ 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 assessor for more information. 0.0050 Local $ 0.00 Thisd�n s does qualify 9 continuance.4/7-2?"--/ j *Delinquent Interest: State $ �! C. 12-L :• ®/ Of — 2?/ 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 RCW,shall be due and payable by the seller or transferor at the time of sale. *Affidavit Processing Fee $ dere) (3) OWNER(S)SIGNATURE Total Due $ 10.00 .L.E46i . ./L _ .l ilD, ,i)r w11 I / PRINT NAM A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS d.1111 I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of / (-"-' •gnature of > Grantor or Grantor's Agent i' f t it _AL % antee or Grantee's Agent Mi r ,� Name(print) 7'00 ‹. .1/iv , TGrt� Name(print) G e 0 r 1p E �, 14' .I I�I f..I G vi Q ts,w,.. Date&city of signing: • � J ` 547D ate&city of signing: r 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(129e9A`2.0.020(IC)). c REV 84 0001a(01/04/16) THIS SPACE-TREASURER'S USE ONLY Cif) COUNTY TREASU ER m 7,41941 125223 *4/22,12016 10,0031 12522 Parcels B, G altri, as shown on the Carstensen Estate Survey recorded November 6, 1997, in Volume 19 of Surveys, pages 79 and 80, records of Jefferson County, Washington, which survey is a revision of the survey recorded in Volume 19 of Surveys, pages 31 and 32, being a portion of the Southeast Quarter of Section 10, Township 28 North, Range 1 West, W.M. , Jefferson County, Washington. 4 4