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Home My WebLink About125263 'Vit . L' Department of .. Revenue Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This farm isyour receipt PLEASETYPE OR PRINT CHAPTER 82.45 RCW—CHAPTER 458-61 A WAC when stamped by cashier. THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED (See luck of last page for instructions) 0 Check bare it partial gale of property Ifmulteple awns.IW percentage of ownership non to name. nName Rnnekt U7nlac Suceessnr TrurstPe of U Name Judith L Haden.a married woman as her ee AFu`hnlas M Gerich RPvnoahlP Trim!'R/4/9111I gennrnle ESODErty 1S Mailing Address 340 ROSS Way V Mtadtng Address 150 Marge Street 64 c'fi Cily/State!£p Sacramento CA 95864 ?t..-- city/state/Zip Port Townsend.WA 98368 Phone No.(incladmg arca code) Phone No(inclodengacca code) U Seed all property tax rmrespondence lo:OSamc as Buyer/Grantee List all rest and persona Property lax parcel accotml Listassessed value(s) numbers—check box if personal property Name n Mailing Address 440 RBn 814 n City/State/Zip n Phone No.(including area code) - n IIIStreet address of property: vacant This property is located to Jefferson County 0 Check box if any of the listed parcels am being segregated foam another parcel,are part of a boundary line adjustment or parcels bang 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 01 Jefferson County,Washington. Select Land Use Code(s): U List all personal property(tangible and intangible)included in selling 1111 It-hoc Rootohote.euda bully elan price. enter any additional codes: None (See back of last page for instructions) YES NO Was the sola receiving a property tax exemption or defatal under 0 ❑ dtaptas 8436,8437,or 84 38 RCW(nemprofitorpovation,senior • citizen,ardimbledpersnq)wmeawoawith lmitedincome)? U - YES NO if claiming an exemption,list WAC number and reason for exemption: Is this prupertydesignatedasforest lead padtapterR433RCW? ❑ El WAC No.(Section/Subsection) WAC 458.61A210(11 Is thisproperty classified as current use(open space,farm and 0 0 agricuhuml,ordrnber)Imhdperdtaptrr8434 RCW? Reason for exemption Ls this property receiving special,adstinaashistorical property ❑ 0 distribution to trust beneficiary--see deet of Ronald per rasap(a84.:6RCW? Uzelac attached ffmryanswers oreyes,complete asinstructed below. Type of Document Quit Claim Deed (t)NOr1TCEOFCONI'EYUANCE(FOREST LAIt,9ORCURREffUSE) 1/1/ /A / /� NEW OWNER(S):To continue the current designation as forest land or Date of Document I1 GAJ// (/ classification as assent use(open space,farm and agriculture,or timber)land, J you must sign on(3)below.The county assessor must then determine if the Gross Selling Price S . land transferred continues to qualify and will indicate by siping below.lithe *Personal Property(deduct)S land no longer qualifies oryou do not wish to continue the designation or classification,it will be=nosed and the compensating or additional taxes will Exemption.Claimed(deduct)S be due and payable by the seller or transferor attiretime ofsale.(RC'W Taxable Selling Price$ 0.00 84.33 I40orRCW 84.34.104 Prior to signing(3)below,you may contact Excise Tax:State S 0.00 ' your local county assessor for mare information. 0.0050 I Local.$ 0.00 This land ❑does 0 does not qualify for continuance. *Delinquent Interest:State S • Local S DEPUTY ASSESSOR DATE (2)NOTICEOFCOMPLIA cCE(HISrORICPROPERTS) *Delinquent Penalty S NEW OWNER(S):To continue special valuation as historic property, Subtotal S 0.00 sign(3)below.If the new owners)does not wish to continue,all *State Technology Fee 5 5.01) 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 Fcc S 5.00 (3)OWNER(S)SIGNATURE Total Due S 10.00 • PRINT NAME A MINIMUM OF SI0.00 IS DUE IN FEE(S)AND/OR TAX ..SEE tesSTRUCTTONS aICERTIPYUNDER PENALTY OFPEj. THAT THE FOREGOING IS TRUE . "iRREGI SignGrantor or Grantor's Age of ,<I `•��= c •iraatee of / 47 l Grantee or Grantee's Agent A! . 4 Name(print)_ Ronald Uzelac,Successor Trust:: si a(print) Judith L Ha.e - iik R Date city ofsignin �r�-- r /n. ismi tL. —`-, .rs/ � ,,� .e&cityofsigningl`V '// Perjury:Perjury is a class C felonry which is punishable by imprisonment in the state correctional institution for a maximum term of not more than five yeas,orby a fine in an aunxmt fixed by the court of not more than five thousand dollars(S5,000.00),or by both imprisonment and fine(RCW 9A 20 020(lC.)). REV 840001a(t2/17/14) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER 748198 1252644,l 016 y_ 001: y\\O 1 • 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 subject real property has now been transferred into the said revocable trust, and this declaration is made with regard to the transfer out of the trust to the ultimate beneficiary Judith L. Hagen. SIGNED at Sacramento, California this f day of '` `_: ,' , 2016. RONALD UZELAC . , as 598913 PGS : 3 AFF 04277/2016 02::18 PM $75,00 COHENMRNNNI THEUNE & MANN/ LLPl se in Car roll, u dlfor■1 .1 W . fiI. �10 ilRose kVON II III i' AFTER RECORDING RETURN TO: JACOB COHEN Post Office Box 889 Oak Harbor,WA 98277 41111111\) AFFIDAVIT RE:LACK OF PROBATE OF THE -I,. . 'TESTAMENT OF NICHOLAS M. '• Grantor: Uzelac,Ronald Grantee : General Public Abbreviated Legal: Lot 14,in Cape Geo �.a Village 0 •, o. 4, as per plat recorded in Volume 4 of Plats,p.:1,-, 5 and 76,records of Jefferson County, Washington. Tax Parcel No.: 940 800 014 • *** * * *** ****** STATE OF CALIFORNIA ) . COUNTY OF _.:. .r 1;► Ronald Uzel. • -E c ,.. t w ••. , om on oath,deposes and says:I was nominated as the Executor of the L, ' .•. :Iv ent of Nicholas M.Gerich.The original Last Will and Testament of Ni ,• . 4 . a' has been filed with the Clerk of the Superior Court of Jefferson County,Washin •'. 'N4- ` ath Certificate for Nicholas M.Clench has been recorded with the Jefferson Co. •ighl, ••r. Prior • 1. <,-,i. Nicholas M.Gerich executed a document known as the"Nicholas M. Geric. t •,1W Trust"and an"Amendment to the Nicholas M.Gerich Revocable Trust".Both e •- __ the • : and the amendment to the trust have been recorded with the Jefferson • A , or.Unfortunately,after the execution of the said trust and amendment thereto, 1 598913 Page 2 of 3 04/27/2016 02:18 PM Nicholas M.Gerich purchased a parcel of real property in Jefferson County,Washington and forgot to include the said real property within the trust.The aforesaid real property is the following real property situated in the County of Jefferson,State of Washington: 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. Tax Parcel No.:940 800 014 Rather than file the Last Will and Testament of the aforesaid D- -fibroma County for probate,the procedure used to transfer the above-de..,' =. :. . ,. to Judith L. Hagen was to record a Quit Claim Deed transferring the •, .'ect . ..,yy .,. the Decedent's two surviving children Judith L.Hagen and Mark S. /-c to R• : • s zelao,as Successor Trustee of the aforedescribed trust,as amended,and ' , the Successor Trustee Ronald Uzelac quit claim the subject real property to th • b eficiary Judith L.Hagen.Said procedure was followed,and said Quit C s have been recorded in the records of the Jefferson County Auditor. All of the debts of the aforenam r� own, '.chiding but not limited to ail expenses of the Decedent's last illness and :..• b�`�'a..enses have been paid in full.There is no United States estate tax or Waslii - :. - I- lance taxes due and owing as the Estate of Nicholas M. Gerich,due to its �` is :a •pt from the filing of the United States Estate Tax Return and/or Was s • * I PII. Return. The De. .- k n-v - :.. from the State of Washington assistance consisting of nursing facility . .m-or community based services,related hospital or prescription drug services,or any . of medical assistance. This • i.':vi is :de to induce any title company relying on this Affidavit to insure title to any real . .ran E ef'erson County,Washington in which the Decedent had an interest at the '•.e o and the said title company may issue its policy or policies in full reliance on + y• ions made herein.Ronald Uzelac,in his capacity as the Successor Trustee of / 2 598913 Page 3 of 3 04/27/2016 02:18 PM the above-described trust,does hereby indemnify and agree to hold harmless any title insurance company which relies hereon by reason of insuring and reliance on these representations. • a1 ♦ . 'ON D UZE gr. C SUBSCRIBED AND SWORN to before me this Rt day of ;A 2016. °NIS .. , ELLEN ANGELL° Commission*2065360 /�I� . �Akk 10111',. r NOTARY P . :, t the State of Notary Public-CalNornia > Sacramento CounEY • Comm.Ex iros Ma 20,2418 California resid lriei., "�O My C.,,i„ission M zot5 . a t&.<> 4N / 3