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Revenue
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REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt
PLEASE TYPEOREUNT CHAPTER s.".4-5 MCW—CHAPTER 4,f,,,..t,,..-.,,V-,Arr when siamped by cashier.
TIRS APPRIATTE WILL NOT RE ACCEPTED UNLESS ALL AREAS ON AU-PAGES ARE MILEY COMPLETED
(See back Mint page for instructions)
0 check box ifpartie sale uf MonenT If mukiple ovum list percentage&ownership' next kt nano.
!I Nazar Patricia Ross(4%) MI wpm Heiman Moreno and Virginia Moreno(96%)
la ii4
1.3 i W
madmg Address6546 San Homero av Husband and Wife
mews Address 1361 W.18th Street
4 ••
Ito a C'todStatraip Buena Park,CA 90260 RI Utyistatetrap San Pedro,CA 90732-4009
0.
I Phone No.(incluffrag area cade)(714)826-7966 Phone No.(including area code)
ill
List all real and persomd property tax parcel account Send all property tax corterpondence ex 0Same as Buyer/Granke List assessed value(s)
numbers-cheek box if parvInd PrePertY 4 . ,
Name Herman Moreno and Wanda Monacan Parcel No.001275031/ID 11182 0 I'13) 220.o0
Madiag Address 1361 W.18th Street
n
1 City/statraip San Pedro.CA 90732-4009 n
1 Phone Nix(including area code) n
5 Street address of property:Woodland Ms No.1 Lot 39
This property is located in Part Townsend
0 Check box if any of the listed parcels arc being segregated from another-pared.arc part of a boundary line adjustment or parcels being merged.
Legal description of phipmty(if more space is needed,you may attach a separate sheet to each page of the affidavit)
Lot 39 of Woodland Has No,1,a survey recorded March 7,1990 in Volume 11 of Surveys.Pages 50-53.under Auditor's
File No.32888*,Records of It:Season away.Washington,and being portions of Sections 27.28,33,and 34,Township 3C
North,Range 1 West.W.M.,Jefferson County.Washington
aSelect Land Use Code(s): 5 List all personal property(tangible and intangible)included in selling
9--Undavi'eited a-d.:i-r.'-..ar.::. 1 I price.
enter any additional codes:
(See back of last page for instructions)
YES NO
Was the selleruceiving apropely tax ear:alpaca or Menai under 0 0 1
chapters'4.3:-.7.,‘it-1...;-,or,-:..-1:-Fa'.,.'traroprofit ortinMsatiorbsetiee
citiam,ordisaliedpesokhomenwnerwithlimiudincomer I
MIyEs No If claiming an exemption,list WAC number and reason for exemption:
Is des PrellelY defigssledas feestlandperdrapter.-4,1 R.-.-v..? 0 0 WAC No.(Section/Subsection)
is disproperty clinsaTtedas anent use(menspme,farin and 0 0 1
i Reason for exemption
agriculaird,ortimber)landperdsaper'--:.%-:',4..r-w?
}
Is thispropettyreceivingspecialvattonionashimaricalproperty 0 0 I
perchaper S-t,t!'-t Rt'Al
ffany answers areyes,cornplee as instrwirxtbelow.
1 Type of Document (lull aelie Deed
(1)NOTICEOF CONTINUANCE(FORESTIANDORUfftRENFUSE)
NEW OWNER(S):To continued=currentdesignation as forest land or !,Date of Document 3128116
classification as corremuse(open space,
is and apiculture,or timber)land
Gross Selling Price 5 6.000.00
you must stgo on(3)below.The county assessor must dun determine if the
land trimsfened matinees to cprafify nodwill indicate by sive*below.Ifthe I *Personal Plop:ay(deduct)5 0.00
land no longer mardifes or you down wish to continue the designation or
Exemption Claimed(deduct) 5 0.00
classification,it will be removed and the compensating or additienal taxes will
60
00 00
be doe and payable by the saes.transtraor at thetirtime ofsain(1:c,,,. Taxable Selling Price $ ,
-,--.-.,'..,...14,1 or Iii':'..,,,4--.,=•1:41.PliCir to spein'g(3)bekxv,yottmay=tact Excise Tax:State $ 76 alb ---
your local county assessor fermate inky:nation_ — -
Loral 5 3 0 JP 00
This land 0 does Efdoes not qualify for continuanc. *Delinquent Interest:State $
Local $
DEPUTY ASSESSOR DATE
*Delinquent Penalty$
CE)NOTICEOFCOMPLIANCE(HISTORICYROMRTY)
I 06.80
NEW OWNER(S):To continue special valuation as baStoric property, Subtotal$
dap(3)below.Witte new owner(s)does not wish to continue,all *State Technology Fee$ SW
additional tax calculated prasumat to chapter---',' -Rt"-•.,,,shall he doe and
' payable by the seller or transferor at the mu of sale. A* ffidavit Processing Fee S 5-doo
(3)OWNER(S)SIGNATURE I Total Due $ ii 6.90.
PRINTNAME A MINIMUM OF 510.00 IS DUE IN FEE(S)At4D/OR SAX.
'SEE INSTRUCTIONS
ia
111 I MCGEE,-,t, a t ol 51' TY Pi s i, THAT IHE FOREGOING ISTRUE AND .
., ..
Signature of /,
Signature
.......c e-_., - v .e......, of
Grantor or-GrurAto , ,, %pi .,, *lejkjele5
r's-
Grantee or Grantee's Agent# dr-24r..A.6 '''
Name(print)11/1"/ Irtv __/ Name(printi4rativagrotgualitEN b
A
Date&city of igning: ci ni it- fzii 4 'Date&city of e'eniog-1--,ZY•-1 t SirAt it let WO
Perjury:Perjury is a class C felony which is punidaht.-by impisonment in the state correctional institution for a maximum term of not more titan free years,ca-by
a fax in an amend fixed by the corm ofnot more than five thousand dollars($5,000.00),or by both impriscamient and fme(PC.,,,,:,,,..N..:,r,,,,:,',ti c)).
REV 84 0001a(01/04/16) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER
, N747391 12256 4:4/26,12016 117,:144:
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