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HomeMy WebLinkAbout125267 ,cam`((,, Department of ere-4- ' yr,,, ,-7 U Washington State )_`) C REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT CHAPTER 82.45 RCW—CHAPTER 458-6 I A W AG when stamped by cashier. THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED (See back of last page for instructions) ❑ Check box if partial sale of property If multiple owners,list percentage of ownership next to name. 0 Name Therald F.Todd and Betty Todd,husband and wife © Name Therald F.Todd,a married man,as his separate property Po m J Mailing Address 4505 Holcomb Street Fz Mailing Address 4505 Holcomb Street rd a 6 City/State/Zip Port Townsend,WA 98368 coia City/State/Zip Port Townsend,WA 98368 Phone No.(including area code)(360)385-9987 Phone No.(including area code)(360)385-9987 © Send all property tax correspondence to:Q Same as Buyer/Grantee List all real and personal property tax parcel account List assessed value(s) numbers—check box if personal property Name 933-300-901 n Mailing Address n City/State/Zip n Phone No.(including area code) n IIStreet address of property: 4505 Holcomb Street This property is located in Port Townsend 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) LOTS 7 AND 8,BLOCK 9,BRACKEN'S ADDITION TO PORT TOWNSEND,AS PER PLAT RECORDED IN VOLUME 2 OF PLATS, PAGE 89,RECORDS OF JEFFERSON COUNTY,WASHINGTON. 1:11‘ Select Land Use Code(s): CI List all personal property(tangible and intangible)included in selling 11-Household,single ramay units price. enter any additional codes: (See back of last page for instructions) YES NO Was the seller receiving a property tax exemption or deferral under ❑ ❑r chapters 84.3 6,&4.37,or 84.38 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? IIYES NO If claiming an exemption,list WAC number and reason for exemption: Is this property designated as forest land pa-chapter 84..33RCW? 0 ❑r WAC No.(Section/Subsection) 458-61A-203(1) Is this property classified as current use(open space,faun and 0 0 agricultural,or timber)land per chapter 84.34 RCW? Reason for exemption Transfer to separate community property Is this property receiving special valuation as historical property 0 ❑� per chapter 81.26 RC\\'? If any answers are yes,complete as instructed below. Type of Document Quit Claim Deed (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) NEW OWNER(S):To continue the current designation as forest land or Date of Document 4/26/16 classification as current use(open space,faun and agriculture,or timber)land, Gross Selling Price $ you must sign on(3)below.The county assessor must then determine if the land transferred continues to qualify and will indicate by signing below.If the *Personal Property(deduct) $ land no longer qualifies or you do not wish to continue the designation or Exemption Claimed(deduct) $ classification,it will be removed and the compensating or additional taxes will be due and payable by the seller or transferor at the time of sale.(RCW Taxable Selling Price $ 0.00 34.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Excise Tax:State $ 0.00 your local county assessor for more infonnation. 0.0050 J Local $ 0.00 This land 0 does 0 does not qualify for continuance. *Delinquent Interest:State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) NEW OWNER(S):To continue special valuation as historic property, Subtotal $ 0.00 sign(3)below.If the new owner(s)does not wish to continue,all *State Technology Fee $ 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 $ (3) OWNER(S)SIGNATURE Total Due $ 10.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS CII CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of Signature ofti /l Grantor or Grantor's nt Grantee or Grantee's Agent ,✓/irM/'r y Name(print) ,t6211114.-- / Name(print) Therald F.Todd Date&city of signing: 4/26/1 Poulsbo,WA Date&city of signing: 4/26/16 Poulsbo,WA Perjury:Perjury is a class C felony which is pturishable by imprisomnent in the state correctional institution for a maxhmun 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 imprisomnent and fine(RCW 9A.2i).020 i IC)). REV 84 0001a(6/26/14) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER -,, 748318 125267 267 , 2_/2016 6 1 I.00* 11 1401 -0