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REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt,
PLEASE TYPE OR PRINT when stamped by cashier. •
CHAPTER 82.45 RCW—CHAPTER 458-61A WAC
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED
(See back of last page for instructions)
File No.58109LS
❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name
1. Name Jefferson Land Trust,as Washington nonpol/fit Name City of Port Townsend,a Washington municipal
corporation, . (� corporation,
n
w O Mailing Address 1033 Lawrence St PP w Mailing Address 250 Madison Street,Suite 2
City/State/Zip Port Townsend,WA 98368 City/State/Zip Port Townsend,WA 98368
c7 Phone No.(including area code) (360)379-9501 c Phone No.(including area code)
3. Send all property tax correspondence to:❑Same as Buyer/Grantee List all real and personal tax parcel account
numbers—check box if personal property Listed assessed value(s)
Name City of Port Townsend 951901102" ❑
5750
Mailing Address 250 Madison Street,Suite 2 951901401 l ❑ 0
City/State/Zip Port Townsend,WA 98368 951902102 v El 1150
Phone No.(including area code) 951903404 V/ ❑ 2300
® Street address of property: XX Atwood St,Port Townsend,WA 98368
This Property is located in El unincorporated Jefferson County OR within❑city of Port Townsend
❑Check box if any of the listed parcels are being segregated from a larger parcel,are part of 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)
V ✓ /
Lots 11 and 12 in Block 11,Lots 1 and 2 in Block 14, Lot 15 in Block 21, Lots 8 and 9 in Block 34, all of Fowler's
Park Addition to Port Townsend; as per plat recorded in Volume 2 of Plats, on page 16, records of Jefferson County,
Washington..
Situate in the County of Jefferson, State of Washington.
® Select Land Use Code(s): 0 List all personal property(tangible and intangible)included in selling
91 price.
Enter any additional codes:
(See back of last page for instructions)
Was the seller receiving a property tax exemption or YES NO
deferral under chapters 84.36,84.37 or 84.38 RCW
(nonprofit organization,senior citizen,or disabled person,
homeowner with limited income)? ❑
121
6. YES NO
Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption:
RCW? El El
Is this property classified as current use(open space,farm and
agricultural,or timber)land per chapter 84.34? ❑ ® WAC No.(Section/Subsection) 458-61A-201 ( .
Is this property receiving special valuation as historical
property per chapter 84.26 RCW? ❑ ® Reason for exemption GIFT
If any answers are yes,complete as instructed below.
Type of Document Quit Claim 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 March 29,2016
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 land transferred continues to qualify and will indicate by signing below. Gross Selling Price $
If the land no longer qualifies or you do not wish to continue the designation *Personal Property(deduct) $
or 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 Exemption Claimed(deduct) $ No
84.33.140 or RCW 84.34.108). Prior to signing(3)below, you may contact
your local county assessor for more information. Taxable Selling Price $
This land CIdoes IDdoes not qualify for continuance Excise Tax: State $
Local $
*Delinquent Interest: State $
Local $
DEPUTY ASSESSOR DATE *Delinquent Penalty $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $
NEW OWNER(S): To continue special valuation as historic property,
sign(3)below. If the new owner(s)do 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$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
UI CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
Signature of Signature of
Grantor or Grantor's Ade "k7-7Chi/iaxe
1 � Grantee or rantee's Ade t`— . ,.-t_yzC t cam.
Name(print)'---dmf anZr`1'rusl (,�vt 51%;24314 Name(print---eit f=1?p € iwasend L,l..rtirty. �jV��l -' °''
Date&city of signing: l(cc I I C. e4_ t�tr'�$t� ' Date&city of signing -1.1(c.n (L_s `Jo of O- n s Fret
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 bi
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(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER
i
State of Washington REAL ESTATE EXCISE TAX
Department of Revenue SUPPLEMENTAL STATEMENT
C Miscellaneous rax Section
PO Box 47477
Olympia WA 98504-7477 (WAC 458-61A-304)
This form must be submitted with the Real Estate Excise Tax Affidavit(FORM REV 84 0001A) for claims of tax exemption as
provided below. Completion of this form is required for the types of real property transfers listed in numbers 1-3 below. Only
the first page of this form needs original signatures.
AUDIT: Information you provide on this form is subject to audit by the Department of Revenue. In the event of an audit,it is the
taxpayers' responsibility to provide documentation to support the selling price or any exemption claimed. This documentation
must be maintained for a minimum of four years from date of sale. (RCW 82.45.100) Failure to provide supporting documentation
when requested may result in the assessment of tax,penalties,and interest. Any filing that is determined to be fraudulent will carry a
50%evasion penalty in addition to any other accrued penalties or interest when the tax is assessed.
PERJURY: Perjury is a class C felony which is punishable by imprisonment in a 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
($5,000.00),or by both imprisonment and fine(RCW 9A.20.020 (1C)).
The persons signing below do hereby declare under penalty of perjury that the following is true(check appropriate statement):
1. H DATE OF SALE: (WAC 458-61A-306(2))
I, (print name) _certify that the__—.__.
(type of instrument), dated , was delivered to me in escrow by —_
(seller's name). NOTE: Agent named here must sign below and indicate name of firm. The payment of the tax is
considered current if it is not more than 90 days beyond the date shown on the instrument. If it is past 90 days, interest
and penalties apply to the date of the instrument.
Reasons held in escrow: --.
Signature Firm Name
2. GIFTS: (WAC 458-61A-201) The gift of equity is non-taxable; however, any consideration received is not a gift and is
taxable. The value exchanged or paid for equity plus the amount of debt equals the taxable amount. One of the boxes
below must be checked. Both Grantor(seller) and Grantee (buyer) must sign below.
Grantor(seller) gifts equity valued at$ to grantee (buyer).
NOTE: Examples of different transfer types are provided on the back. This is to assist you with correctly
completing this form and paying your tax.
"Consideration" means money or anything of value, either tangible (boats, motor homes, etc) or intangible, paid or
delivered, or contracted to be paid or delivered, including performance of services, in return for the transfer of real
property. The term includes the amount of any lien, mortgage, contract indebtedness, or other encumbrance, given to
secure the purchase price, or any part thereof, or remaining unpaid on the property at the time of sale. "Consideration"
includes the assumption of an underlying debt on the property by the buyer at the time of transfer.
A: Gifts with consideration
1. 7 Grantor(seller) has made and will continue to make all payments after this transfer on the total debt of
$ and has received from the grantee (buyer) $
(include in this figure the value of any items received in exchange for property). Any consideration
received by grantor is taxable.
2. P1 Grantee (buyer) will make payments on _% of total debt of$ for which grantor
(seller) is liable and pay grantor(seller) $ (include in this figure the value of any items
received in exchange for property). Any consideration received by grantor is taxable.
B: Gifts without consideration
1.Z There is no debt on the property; Grantor (seller) has not received any consideration towards equity.
No tax is due.
2. ❑ Grantor(seller) has made and will continue to make 100% of the payments on total debt of$
and has not received any consideration towards equity.No tax is due.
3. ❑ Grantee (buyer)has made and will continue to make 100% of the payments on total debt of$
and has not paid grantor(seller) any consideration towards equity. No tax is due.
4. H Grantor(seller) and grantee (buyer)have made and will continue to make payments from joint account on
total debt before and after the transfer. Grantee (buyer)has not paid grantor(seller) any consideration
towards equity.No tax is due.
Has there been or will there be a refinance of the debt? Li YES I I NO
If grantor(seller) was on title as co-signor only, please see WAC 458-61A-215 for exemption requirements.
The undersigned acknowledges this transaction may be subject to,a.0 4 it and have re. a the above information
regarding record-keeping requirements and evasion penalties.
Sar c.,_.A.,_(..5-0()ot-g--14-1,_ c dir _ ''......---
grantor's Signature ' rantee's Signature
3. 7 IRS "TAX DEFERRED" EXCHANGE (WAC 458-61A-213)
I, (print name)_ , certify that I am acting as an Exchange Facilitator in transferring
real property to__ pursuant to IRC Section 1031, and in accordance with WAC 458-61A-213.
NOTE: Exchange Facilitator must sign below. -