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Home My WebLink About125238 7117 VDepartment of evenue 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.82051JMM 0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name 1. Name Sandy L.Morse,as her separate estate Name Thomas E.Schwiesow and Susan E.Schwiesow, husband and wife at O Mailing Address P.O.Box 1344 x F Mailing Address 3335 Wild Goose Rd NE a � z City/State/Zip Bend,OR 97709 City/State/Zip Moses Lake,WA 98837 C., Phone No.(including area code) (541)948-6446 t7 Phone No.(including area code) (509)750-8882 3. Send all property tax correspondence to: ❑Same as Buyer/Grantee List all real and personal tax parcel account Listed assessed value(s) numbers—check box if personal property Name Thomas E.Schwiesow and Susan E.Schwiesow 993 400 019/42176 0 107,203.00 Mailing Address 3335 Wild Goose Rd NE ❑ City/State/Zip Moses Lake,WA 98837 ❑ Phone No.(including area code) (509)750-8882 0 Street address of property: 108 Terrance Lane,Brinnon,WA 98320 This Property is located in❑unincorporated Jefferson County OR within 0 city of Brinnon 0 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) Lot 19, Seamount Estates Division No. 3, as per plat recorded in Volume 5 of Plats, pages 98 and 99, records of Jefferson County, Washington. Situate in the County of Jefferson, State of Washington. Situate on said premises is one 1991 ARDMO 28/48 mobile home;License No.%025984;VIN No. 112005. ® Select Land Use Code(s): 11 7. List all personal property(tangible and intangible)included in selling 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)? 0 x ® YES NO Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption: RCW? 0 x Is this property classified as current use(open space,farm and agricultural,or timber)land per chapter 84.34? ❑ x WAC No.(Section/Subsection) Is this property receiving special valuation as historical x property per chapter 84.26 RCW? ❑ Reason for exemption If any answers are yes,complete as instructed below. Type of Document Statutory Warranty 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 April 11,2016 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 $ 115,000.00 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 $ 115,000.00 This land 0 does ❑does not qualify for continuance Excise Tax: State $ 1,472.00 Local $ 575.00 *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $ 2,047.00 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 $ 2,052.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT Signature of �, a� I Signature of Grantor or Grantor's Ag'411V-11 . i Grantee or Grantee's Agent Name(print) Sandy L. •ore Name(print) Thomas E.Schwiesow Date&city of signing: e.(// 1(0 t + /�v N (Aj14 Date&city of signing 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(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASU i 1252 *4/22/2016 2,052.00* . t a e nerd PLEASE TYPE OR PRINT REAL ESTATE EXCISE TAX AFFIDAVIT This fnnn is you'.=WO CHAPTER 8245 RCW—CHAPTER 458-6IA WAC when stamped by cashier. THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED (See back of last page for instructions) File No.820511MM 0 Check box if partial sale ofproperty If multiple owners,list percentage of ownership next to name I. Name Sandy L.Morse,as her separate estate .Name Thomas E.Schwiesow and Susan E.Schwiesows husband and wife . Mailing Address P.O.Box 1344 Ii Mailing Address 3335 Wild Goose Rd NE City/Statc/2ip BendOR 97709 City/Stale/Zip Moses Lake,WA 98837 EPhone No.(including area code) (541)948.6446 0 Phone No.(including area code) (509)750-8882 3. Send all property tat correspondence to:0 Same as Buyer/Grantee List all real and personalbx iltax parcelprryaccount Listed assessed vahte(s) numbers—check box if personal property Name Thomas E.Schwiesow and Susan E.Schwiesow 993 400 019/42176 0 107 203.00 Mailing Address 3335 Witd Goose Rd NE 0 City/State/Zip Moses Lake,WA 98837 0 Phone No.(including area code) (509)750.8882 0 fl Street address of property:; 108 Terrance Lane,Brinnon,WA 98320 This Property is located in❑unincorporated Jefferson County OR within 0 city of Brinnon 0 Check box if any of the listed parcels are being segregated from a larger parcel,are pan 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) Lot 19,Seamount Estates Division No.3,as per plat recorded in Volume 5 of Plats,pages 98 and 99,records of Jefferson County,Washington. Situate in the County of Jefferson,State of Washington. Situate on said premises is one 1991 ARDMO 28/48 mobile home;License No.%025984;VIN No.112005. ® Select Land Use Code(s): I I ® List all personal property(tangible and intangible)included in selling 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 8436,84.37 or 84.38 RCW (nonprofu organization,senior citizen,or disabled person, homeowner with limited income)? ❑ x ® YES NO Is this property designated as forest land per chapter 8433 If claiming an exemption,list WAC number reasonfor exemption: RCW? 0 s Is this property classified as current use(open space,farm and agriculhnal,ortimber)land per chapter 8434? a WAC No.(Section/Subsection) Is this property receiving special valuation as historical property per chapter 84.26 RCW? ❑ x Reason for exemption if any answers arc yes,complete as instructed below. Type of Document Statutory Warranty Deed (I)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) NEW OWNER(S):To continue the current designation as forest land or Date ofDocuman April 11,2016 classification as current we(open space,farm and agriculture,err timber) land,you must sign on(3)below. The county assessor must then determine if the land transfused continues to qualify and will indicate by signing below. Gross Selling Price $ 115,000.00 lithe land no longer qualifies or you do not wish to continue the designation .Property(deduct) S or classification.it will be removed and the compensating or additional taxes wilt be due and payable by the seller or transferor at the time of sale. (RCW Exemption Claimed(deduct) S 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 S 115,000.00 This land 0 does 0 does no: qualify for continuance Excise Tax: State S 1,472.00 Local $ 575.00 'Delinquent Interest State S Local S DEPUTY ASSESSOR DATE 'Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $ 2 047.00 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 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 $ 2,052.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX 'SEE INSTRUCTIONS ® I CERTIFY UNDER I'ENALTY OF PERJURYTHATTHE FOREGOING ISTRUEAND CORRECT GSiranton of g " 1 4 Sigaateee of ma c_--^r'e J2 . I r i%re GraotororGrantor's A SSL' � ,ry Grantee orGrantePsAtrnt Name(print) Sandy L. ore Name(print) Thomas E.e� lesow Date&city of signing: j 5i /f(a .e�.ryt ,j s . Date&city of signing . is I p U . n ' Perjury:Perjury is a class C felony which is punishable by imprisonment in the state correctional institution foram. imam 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($5,000.0.or by both imprisonment and fane1RCW 9A.20.020(IC). REV 84 000 I a(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER