HomeMy WebLinkAbout125250 Department of
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Revenue frfli
Washington State
REAL ESTATE EXCISE TAX AFFIDAVIT
PLEASE TYPE OR PRINT CHAPTER 82.45 RCW—CHAPTER 458-61A WAC he form your cashier.w
when stamped by
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED
(See back of last page for instructions)
0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name.
0 Name Susan P.Monroe,an unmarried person ®Name S.P.Monroe,Trustee of the Gentillalli Family Living
a Trust,dated July 17,2015
w F Mailing Address P.O.Box 1090 a
..a z z Mailing Address P.O.Box 1090
w<City/State/Zip Port Townsend,WA 98368 MI a City/State/Zip Port Townsend,WA 98368
L Phone No.(including area code) (360)437-9180
Phone No.(including area code) (360)437-9180
III Send all property tax correspondence to:®Same as Buyer/Grantee List all real and personal property tax parcel account
numbers—check box if personal property List assessed value(s)
Name 990400147 0 $23,000.00
Mailing Address 990500024 0 $24,294.00
City/State/Zip 0
Phone No.(including area code) 0
0 Street address of property: Lot 47,Puget Loop And Lot 24 Sparrow Lane,Port Ludlow,WA 98365
This property is located in®unincorporated Jefferson County OR within 0 city of Port Ludlow
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)
Parcel A:
Lot 47,Area 1,Port Ludlow No. 1,as per Plat recorded in Volume 5 of Plats at pages 26 through 32,records of Jefferson County,
Washington.
Situate in the County of Jefferson,State of Washington.
Parcel B:
Lot 24,Port Ludlow No.4,as per Plat recorded in Volume 6 of Plats at pages 54 through 56,records of Jefferson County,
Washington.
Situate in the County of Jefferson,State of Washington.
n Select Land Use Code(s): Q List all personal property(tangible and intangible)included in selling
91,91 price.
enter any additional codes:
(See back of last page for instructions)
YES NO
Is this property exempt from property tax per chapter ❑
El
84.36 RCW(nonprofit organization)?
0 YES NO If claiming an exemption,list WAC number and reason for exemption:
Is this property designated as forest land per chapter 84.33 RCW? 0
WAC No.(Section/Subsection) 458-61A-211(cA,
Is this property classified as current use(open space,farm and
agricultural,or timber)land per chapter 84.34? ❑ ® Reason for exemption Transfer to Living Trust
Is this property receiving special valuation as historical 0
property per chapter 84.26 RCW?
If any answers are yes,complete as instructed below.
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) Type of Document Quit Claim Deed
NEW OWNER(S): To continue the current designation as forest land or
classification as current use(open space, farm and agriculture,or timber) Date of Document April 25,2016
land, you must sign on (3) below. The county assessor must then
determine if the land transferred continues to qualify and will indicate by Gross Selling Price $
signing below. If the land no longer qualifies or you do not wish to *personal Property(deduct) $
continue the designation or classification, it will be removed and the
compensating or additional taxes will be due and payable by the seller or Exemption Claimed(deduct) $
transferor at the time of sale. (RCW 84.33.140 or RCW 84.34.108).Prior Taxable Selling Price $
to signing(3)below,you may contact your local county assessor for more
information. Excise Tax: State $
This land 0 does 0 does not qualify for continuance. Local $
*Delinquent Interest: State $
DEPUTY ASSESSOR DATE Local $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) *Delinquent Penalty $
NEW OWNER(S): To continue special valuation as historic property, Subtotal $
sign (3) below. If the new owner(s) does not wish to continue, all
additional tax calculated pursuant to chapter 84.26 RCW,shall be due *State Technology Fee $ 5.00
and payable by the seller or transferor at the time of sale. *Affidavit Processing Fee $ 5.00
(3) OWNER(S)SIGNATURE Total Due $ 10.00
PRINT NAME A MINIMUM OF$10.00 IS DUE 1N FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
® I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Signature of AO1I/�,�
Grantor or Grantor's Agent Grantee or Grantee's Agent 4 144vV1.-42._
Name(print) Susan P.Monroe Name(print) S.P.Monroe,Trustee 9A4 jw
Date&city of signing: L(-g 5-((♦p 1),,C-l-T CI,Jv15,F.,4 Date&city of signing: Li-a' -I ls, e -1--1 Ot yl
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)).
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THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER I
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