HomeMy WebLinkAbout125261 „",,i,-.:-. ( ;t'.1 1 ---
Department of ems!
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Revenue "ir-_ MOBILE HOME � j�, .)Washington State REAL ESTATE EXCISE TAX AFFIDAVIT r
Submit to County Treasurer of the county Chapter 82.45 RCW This form is your receipt when stamped
n which property is located. Chapter 458-61A WAC by cashier.
FOR USE WHEN TRANSFERRING TITLE TO MOBILE HOME ONLY
PLEASE TYPE OR PRINT
INCOMPLETE AFFIDAVITS,y�IWILL NOT BE ACCEPTED
Q Name CJ 1 v� Me‘›S K r��(JS{ p Name
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Name Name
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-a Street Street
,. 2 City State Zip Code City State . Zip Code
PERSONAL PROPERTY REALPROPERTY
PARCEL or ACCOUNT NO. PARCELorACCOUNT NO. 118- 7a0 -/0 T /c'27,5er
LIST ASSESSED VALUE(S):S LIST ASSESSED VALUE(S):S
REVENUE TAX
MAKE YEAR MODEL SIZE SERIAL NO.or LD.
j3 CODE NO.
z cts:'L' /(., e`A if(AD Sc' ff-
10ps39y"S1Gotco-
2LIU
Date of Sale
41 - 7 7_ /c c c,.i+Gz46 7'
AFFIDAVIT
Taxable Sale Price
$ /5t Q c,
Lcertify under penalty of perjury under the laws of the State of
Excise Tax: State $ 1907.0 0 Washington that the foregoing is true and correct.
ct Location Local $ 76,Oo
Signature of /�
Delinquent Interest: State $ Grantor/Agent 1 '� ” ' ��1��. ^tcj IR U$r E-
Local $ Name(print) Ki V . me ss-;
Delinquent Penalty $
Subtotal $ a6 00 ( Date and Place of Signing d �(}t t I)S��,�( cool_
2_-7Ic,
State Technology Fee $ 5.00
Affidavit Processing Fee $ Signature ofE J
Grantee/Agent
Total Due $ .7 oQ.00 3446
Name(print) R.-e-- -�- '' 'k i'`i ?7 --
If exemption claimed,WAC number&title:
WAC No.(Sec/Sub) Date&Place of Signing: 1 1 11)ir T
WAC Title
A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX.
TREASURER'S CERT ICATE
I hereby certify that property taxes due .111-4.4441`/ If,in selling(or otherwise transferring ownership of)a mobile home
which possesses a tax lien,the seller does not inform the buyer(new
County on the mobile home described her n have been paid to and owner)of such a lien,the seller is guilty of deliberate deception as it
including the year &O applies to Fraud and/or Theft as defined in Title 9 and 9A RCW(RCW
q/A 7/ o i ce 9S4242.46-•44- 44. 9.45.060,RCW 9A.56.010(4d),and RCW 9A.56.020).
Date County Treasurer or eputy
THIS SPACE-TREASURER'S USE ONLY
Nic748.137 125261 4:4/27/2016 272 001:
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