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Home My WebLink About125270 t 4 N � /5O • Department of re ('`�) c[ �% Revenue Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT CHAPTER 82.45 RCW—CHAPTER 458-61A WAC 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 Debra A.if IJ.L' Gl Dominici p�_.� d and Doualas P. Jones ® NameTibbals Lake Farm LLC t 66 r.,. L c:.. 0... ed c4 di o . °../0W a z MailingAddress538 Fillmore Street w Mailing Address 538 Fillmore Street cn( City/State/Zip Port Townsend WA 98368 m a City/State/Zip Port Townsend WA 98368 Phone No.(including area code) Phone No.(including area code) a Send all property tax correspondence to: ✓ List all real and personal property tax parcel account p perty p ❑Same as Buyer/Grantee numbers—check box if personal property List assessed value(s) Name 999000901." 999007802 0 6119,350, $504,815 Mailing Address 1i9 b ba is La i Pe y�,, ❑ City/State/Zip g1 0 G :-9 ,$ (-10 1 n Phone No.(including area code) efe,}( c 2) (pa v(tt ) n in Q p / INStreet address of property: 425 Cook Avenue Extension,Port Townsend WA 98368 This property is located in Jefferson County 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 1 through 10 inclusive,Block 9,Tibbals Lake Park Addition,as per plat recorded in Volume 2 of Plats,page 3,records of Jefferson County,Washington. Parcel 8 of Survey recorded in Volume 16 Of Surveys,page 195,and further described in Boundary Line Adjustment recorded under Auditor File No.374391,said survey being a portion of the Supplemental Plat of Captain Tibbal's Lake Park,as recorded in Volume 2 of Plats,page 3,a portion of Sections 4 and 5,Township 30 North,Range 1 West,W.M.and Sections 32 and 33,Township 31 North, Range 1 West,W.M.,records of Jefferson County,Washington. Select Land Use Code(s): © List all personal property(tangible and intangible)included in selling 1-Undeveloped land(land only) aprice. enter any additional codes: 11 N/A (See back of last page for instructions) YES NO Was the seller receiving a property tax exemption or deferral under 0 0 chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? IIIIYES NO If claiming an exemption,list WAC number and reason for exemption: Is this property designated as forest land per chapter 84.33 RCW? 0 0 WAC No. (Section/Subsection) 458-61A-211 C I� Is this property classified as current use(open space,farm and 0 0 • Reason for exemption agricultural,or timber)land per chapter 84.34 RCW? Mere change in identity or form;no change in beneficial interest Is this property receiving special valuation as historical property ❑ 9 per chapter 8426 RCW? If any answers are yes,complete as instructed below. Type of Document Quitclaim 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 4/28/16 e classification as current use(open space,farm and agriculture,or timber)land, 0.00 you must sign on(3)below.The county assessor must then determine if the Gross Selling Price $ 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.(R('.W Taxable Selling Price $ 0.00 84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Excise Tax : State $ 0.00 your local county assessor for more information. 0A050 Local $ 0.00 This land 0 does 0 does not qualify for continuance. *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) *Delinquent Penalty $ 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 ® I CER FY N► R PENALTY OF PERJURY THAT THE FOREGOING IS TRU r AN► C AlA CT. or Signature of `,� Signature of /p'C' Grantor or Grantor's Agent // Grantee or Grantee's Agent ,�A Name(print) Douglas G. Mason, • orney at Law Name(print) Douglas G. Mason,Attorney at Law Date&city of signing: Date&city of signing: Perjury:Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a maximum 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 imprisonment and fine(RCW 9A.20.020(1 C)). REV 84 0001a(01/04/16) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER :;.'t.. _ 1252;'1.f _ . 2,01c, 10a00"* I 2G-2,1 AFTER RECORDING RETURN TO: Douglas G. Mason, Attorney at Law 2404 35th Street Port Townsend WA 98368 Abbreviated legal description: Lts1 To 10 Blk 9 Tibbals Lake Park&Parcel 8 Survey 16/19 Affects assessor's parcel numbers: 999 000 901, 999 007 802 QUITCLAIM DEED The Grantors, DEBRA A. DOMINICI, a single woman as to an undivided 51% interest and DOUGLAS P. JONES, a single man as to an undivided 49%interest as tenants in common,for no monetary consideration and in order to transfer real property to a limited liability company with no change in the beneficial interest of either of the Grantors, convey and quitclaim to the Grantee herein, TIBBALS LAKE FARM LLC, a Washington limited liability company,all of the right, title, and interest of Grantors in and to the real property situated in Jefferson County, Washington, described in the attached Exhibit A, incorporated herein by this reference, together with all after acquired title of the Grantors. Dated: '1�g, • rIM- ...__ _____mialte.v Debra A. D•min ci /11611111 ft Dou• as P. Jones STATE OF WASHINGTON ) ss. COUNTY OF JEFFERSON ) I certify that I know or have satisfactory evidence that DEBRA A.DOMINICI and DOUGLAS P.JONES are the persons who appeared before me, and said persons acknowledged that they signed this instrument and acknowledged it to be their free and voluntary act for the uses and purposes therein mentioned. GIVEN und- j • -nd official seal this day of Af t 1 , 2016. 0Signatur- d J 046,,s k" ��5e, Printed name NOTARY PUBLIC, State of Washing n Residing at fa e I. 1 iv,) t.e4A4 Notary Public : e •• MASON 1 �