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HomeMy WebLinkAbout125233 IN ick_0;\ .-)Os3 Department of (-2( s-c.:-- 4---)_ -- 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. 0 Nin &G 1;de,4 6 P'a rYZ t. r-xc fili-lil Name C o$r F e.I .�i Weil c3 Y3-CJ a4 43--,lbr., iari >ne4a tisces ef-t '7°its - QZ.S39 Asl-. yAVe . a z Mailing Address ��'ye tU z Mailing Address 1�&�(/ CA _ City/State/Zip L 1 _ /o a-�f .;. City/State/Zip 71'70 7-- Phone No.(including area code)'. a .-- Ya . ' 8 Phone No.(including area code) a ` 8 / - a.....1,6--:a List all real and personal property tax parcel account © Send all property tax correspondence)to:w0 Same as Buyer/Grantee► / numbers-check box if personal property 4 List assessed v (s) Name &"Qld .t j I ID lc�l ma illi / , :,:�g12 `` ),� 0`7alue7 Mailing Address ,2..g 39 A.Kh,/' Avei2e 4703'p-1 il'' City/State/Zip 13 ',BGG i CA 9117 05' `ct' l i 9&` '105 Phone No.(including area code, ..1 6,s.7—...),2 6"$ miStreet address of property: 70.3 ✓L-- ,.54-)--e elf- Tb Y 1-6,W 7 .'Cr'I C' WA ? 34 J e This property is located in Jefferson County fC 3?>7 ,)3eK (old --S-.25:4-.,,,,-�6, Cy s Siy?�`ik . r`Tivt.v 1 >35D 0 Check box if any of the listed parcels are being segregated from another parcel,are part of��a bo��Baryliine adjustment or paareing merged. 1 Legal description of property(if more space is needed,you may attach a separrshe'etto iac"h page otf tht a i avt't) � I '\ 703 41 .5 .G.ci s 2Q' 4j "Brock, 55 o +G 6�Wci t-h e Su p)*c,r-yt�i- c,1 Pl� - �-� "red�ty r�v e, s F,r S* Ad d i- I c7 r` to --1-1m. Ci•ty a* r'+ TD r t e ngt, Q3 per r1a..+ I-CC-0 rifled Pi � e-- 1 r0 f P1 ilis, 7'e-� . -� , , �a r�� 'e ,l's�t Co ,l r�}� NAla.s 1-�.i v,�-hv-N . )o3 c iii4.h cur 4,- ci..cguor ct-f',4.1e. o Int. is> -0r herd in --ra)c p0. t ' ?9i-/ 90.5- .5"0L Select Land Use Code(s): Select Land Use Codes I List all personal property(tangible and intangible)included in selling price. /10 w � & Lar�.i 7,03 Liz ,5 �-e.e,.-t enter any additional codes: // Alit rZ r l (See back of last page for instructions) ,n -- Csc � h --Vorn b� Com/ YES NO 'Y ee- 70`` 7 CAt�L'c'''t..1�-j' Was the seller receiving a property tax exemption or deferral under X ❑ f zv c2 e,„� (4,p .r✓5' 0 1 chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior. 644.i. '� ”Z citizen,or disabled person,homeowner with limited income)? has, E,,Qt v cykEd :far. epic., ,c)/1 iii YES NO If claiming an exemption, list WAC number and reason for exemption: QQ i�1 � Is this property designated as forest land per chapter 84.33 RCW? 0 WAC No. (Section/Subsection) 95O'`P`A^a.'(j Is this property classified as current use(open space,farm and 0 �'n agricultural,or timber)land per chapter 84.34 RCW? Reason for exemption \I�VI .-0,0(—R._. Is this property receiving special valuation as historical property ❑ k per chapter 84.26 RCW? If any answers are yes,complete as instructed below. Type of Document a fr Cha\ vv\ Q( G(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) , ` tINEW OWNER(S):To continue the current designation as forest land or Date of Document `' Lo 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 assessor for more information. 0.0050 Local $ 0.00 This land ❑does 0 does not qualify for continuance. *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 $ 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 $ (3) OWNER(S)SIGNATURE Total Due $ 10.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS © I CERTIFY UNDER PENALT • 'ERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of L Signature of Grantor or Grantor's Agent ' Grantee or Grantee's Agent C c' 2- ----. Name(print) 6 R&f•(E t- *0 1 A ML1 t►ti'17. Name(print) &A 171?IC 1_, A. D IA Ole NV D Date&city of signing:4/2ftt o.-J��wNzNl), LJA Date&city of signing: V/2-1 I/ (6 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(01/04/16) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER INQ(01--- 12c 2223