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Nbrhry;tan State
This form is your receipt
PLEASE TYPE OR PRINT REAL ESTATE EXCISE TAX AFFIDAVIT 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.82065JMM
0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name
I. Name Silas L.Smith and Carotene S.Smith,husband and Name Bruce Larson and Kathryn Larson,husband and
wife wife
x O Mailing Address 61 Canal Lane c w MailingAddress 6262 Vassar Ave NE
Z
City/State/Zip Brinnon,WA 98320 City/State/Zip Seattle,WA 98115
(7 Phone No.(including area code) (360)796-3489 (•7 Phone No.(including area code) (206)409-8589
3. Send all property tax correspondence to:0 Same as Buyer/Grantee List all real and personal tax parcel account
numbers—check box if personal property Listed assessed value(s)
Name Bruce Larson and Kathryn Larson 980 100 319/36826 0 z,4.17 —
Mailing Address 6262 Vassar Ave NE <91 (e'7/ g
City/State/Zip Seattle,WA 98115 0
Phone No.(including area code) (206)409-8589 0
1111 Street address of property: 61 Canal Lane,Brinnon,WA 98320
This Property is located inA unincorporated Jefferson County OR within y'ty ' n f--"
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 21 in Block 3 of Olympic Canal Addition No, 1, as per plat recorded in Volume 4 of Plats, page 33, records of
Jefferson County, Washington.
Situate in the County of Jefferson, State of Washington. Q,_
�. p ,Select Land Use Code(s): 11List 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)?
❑ 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
property per chapter 84.26 RCW? ❑ x Reason for exemption
If any answers are 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 of Document April 19,2016
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 $ 340,000.00
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 $ 340,000.00
Excise Tax: State $ 4,352.00
This land 0 does 0 does not qualify for continuance
Local $ 1,700.00
*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 $ 6,052.00
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 $ 6,057.00
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 / . Signature of
Grantor or Grantor's Aleut ,r �� „� .Z Grantee or Grantee's Agent
Name(print) Silas L.Smit Name(print) Bruce Larson
Date&city of signing: 44 el JLir p.1 Date&city of signing [_/Z-///6 c"--7.p
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 TREASURER
JA-V
742884 125248 *4/25/2016, 6 05700*