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Department
Washington Scats REAL ESTATE EXCISE TAX AFFIDAVTI
This farm is your receipt
PLEASE TYPE oR PRINT CHAPTER 82.45 RCW-CHAPTER 458-61 A WAC when stamped by cashier.
THIS AFFIDAVIT WILL NOT RE ACCEPTED UNLESS ALL AREAS ON ALL PAC ES ARE FULLY COMPLETED
(Sec tuck of last page for instruction)
El Check box dpartial salt of property If multiple owners,list percentage of ownership next to acme.
®Name .1i HIM I Hanark,l3,,isA sky-Y,r' U,;Gr\O 1\ OSEl Name Ronald Uzelac,Successor Trustee of
,4`N v- 5'I 9e. k"'c-ft a A-1 (SA( c • Irl. m TVlcholaa M.Gerich Revocable Trust 8/4/2011
fi
4 Mailing Address I hi:a• i i - r' .a Ct.Sin Mailing Address 340 Ross WaV
aCity/statdLp Pori Townsend W9 9,8368 in g city/stacr2.p Sacramento.CA 95864
Phone No,(including arca code) Phone No.(including arca code)
Send all properly tax correspondence to:Q Same as Bu er/Grantee Liu rca!and personal property tax parol neeotmt
numbers-check box if personal property
.+fLiar auessed�rslue(s)
Name /� ri 3) 7)4 )
Mailing Address clAft PIM n14 t�asci(so
f U1 o ri
ovistatdzip f
Ptwaa Na(including area code) I-]
®Street address of property• vacant
This property is located in Jefferson County
[)Check box if any of the listed parcels are being segregated from another parte,am part of a boundary lire 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 14 in Cape George Village,Division No.4,as per plat recorded in Volume 4 of Plats,pages 75 and 76,
records of Jefferson County,Washington.
Select Land Lisa Code(s): ®List all personal property(tangible and intangible)included in selling
Eli
51-Household•alaele harry an:a .------------1 price
enter any additional codes: Nene
(See back of last page for instructions)
YES NO
Was theseilerreceiving aproputytax exemptimordeferral undo 0 RI
chapters 8.1.36,81.37,or84 38 RCA'(ompxa5torganizaiion,senior
citizen or diesbled person homeowner with limited Meaner
® IfYES NO
claiming an exemption,list WAC number and reason for exemption:
w
Is this property tics)glauxiasfon:elandper diaper 84.33RCM Q I1 WAC No.(Section/Subsection) WAG 458-61A-210(1)and(2)
Is this propatyelassifed as rerun use(open space.firm and 0 0
agriatlanal,or timber)land pad>apaer84.74 RCW? Reason for exemption
isthispmpatyreceiving special valuationashistoric&property p no change of beneficial interest&no valuable
pereltapxa8426RCM consideration—see daub of Ronald Uzelac attached
Ifany answers are yes,cmtpleteasinsnaaedbelow, Type of Document OUR Claim Deed
(I)NOTICE OFCON I1 UANCE(FORESTLAND OR CURRENT USE) 3�/�%//b
NEW OWNER(S): et
To continue the me&designation as forest land or Date of Document
classification as current use(open space,farm and apiculture,a timber)land, Gross Selling Pri S
you must sign on(3)below.The county assessor mast then determine if die
land transferred continues to qualify and will indicate by signing below.If the *Personal Property(deduct)$
land no longer qualities or you donut wish to continue the designation or
Exemption Claimed deduct S
classification,it will be=tovod and the compensating or additional taxes will P (deduct)
be due and payable by the seller or transferor atthe timeofsale.(RCW Taxable Selling Price S 0.00
84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Excise Tax:State 5 0.00
your local county assessor fix more information
0,0050 Local 5 0,00_
This land 0does Odom not qualify for continuance.
'Delinquent Interest:State S
Local S
DEPUTY ASSESSOR DATE
(2)NOTICE OFCOMPLIAN(E(EDSrORICPROPERTY) "Delinquent Penalty S
NEW OWNER(S):To continue special valuation as historic property, Subtotal S 0.00
sign(3)below.If the new owner(s)does not wish to continue,all *State Technology Fee S 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 S
(3)OWNER(S)SIGNATURE Total Due S 10.00
- PRI NAM' A MINIMUM OF 510.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
#� ^
u 3/23// . b
a� � -F � ,.:%1..� ] F REGOING]S TRUE. CORRE'"•
Sigma=of v117 t![ // Sinature of / '
Grantor or Grantor's Agen ✓ Grantee or Grantor's A y. ,
Name(print) Judith L Ha rl/Mark S.Gerich
C 1. Name(print) Rona.UzP/Tac SuccessorTrustea 1
Date&city of signing:; J c c I?'4 m4 I/'1tC Date&city of signing 3 1 1 (e . ./.4.Ate...44)r) C'
Perjury:Perjury is a class C felony which is punishable by imprisonment in the sate correctional institution for a maximum teem of not more than fiveyears,or by
a fine in an amount fixed by the court ofnot more than five thousand dollars(S5,000.00),orby both impristxtmest and fine(RCW 9.1.20.020(1C)).
REV r4 soma(12/l2/14) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER /'-
'748198 8 125242 *4/27,12016 10 0:4,
1 ZkeZ
DECLARATION RONALD UZELAC
Pursuant to RCW 9A.72.085, I certify under the penalty of perjury of the laws of
the State of Washington that the following is true and correct:
I, Ronald Uzelac, am the Successor Trustee to the Nicholas M. Gerich
Revocable Trust, copy of said trust agreement together with the amendment thereto is
attached hereto as an exhibit. During the lifetime of Nicholas M. Gerich, he purchased
the real property described in the Real Estate Excise Tax Affidavit and took title in his
own name instead of the name of the Nicholas M. Gerich Revocable Trust.A copy of
the Death Certificate of Nicholas M. Gerich is attached showing that he died on
December 23, 2015. The subject real property should have been placed in the trust
upon purchase, but Nicholas M. Gerich failed to do so. Under the terms of the Last Will
and Testament of Nicholas M. Gerich, copy attached hereto, everything owned by
Nicholas M. Gerich at the time of his death passed to the Nicholas M. Gerich Revocable
Trust. The purpose of the said deed is to place the subject real property into the trust
without a probate, and thereafter, to transfer the subject real property from the Nicholas
M. Gerich Revocable Trust to the beneficiary Judith L. Hagen. Pursuant to the terms of
the trust, after the death of Nicholas M. Gerich, the trust becomes irrevocable.
SIGNED at Sacramento, California this 47 dayof r;_
1 _"" �., ="1 , 2016.
/ j �I</
/ ,//
RONALD UZELAC