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REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt
PLEASE TYPE OR PRINT
when stamped by cashier.
CHAPTER 82.45 RCW—CHAPTER.458-61 A WAC
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED
(See back of last page for instructions)
File No,58043LS
0 Check box if partial sale of property If multiple owners,list percentage ofownership next to name
1. Name Betty Julianne Wynstra 2. Name Casey O.Wunsch,married as separate property
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Mailing Address 365 Seattle Dr cc uj Mailing Address 365 Seattle Dr
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— --. v/State/Zip Port Ludlow,WA 98365 :;) ''' City/State/Zip Port Ludlow,WA 98365-8256
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Phone No.(including area code) (360)865-8996 (L"' Phone No,(including area code) (360)865-8996
3. Send all property tax correspondence to:D Same as Buyer/Grantee List all real and personal tax parcel account
Listed assessed value(s)
numbers-check box it'personal property
35,160
Name Casey 0.Wunsch 950 100 512/28687 0
Mailing Address 365 Seattle Dr 950 100 441 (28677 111 156,480
City/State/Zip Port Ludlow,WA 98365-8256
0
Phone No.(including area code) (360)865-8996
0
® Street address of property: 365 Seattle Dr,Port Ludlow,WA 98365-8256
This Property is located in N unincorporated Jefferson County OR within D city 01 Port.Ludlow
0 Check box if any of the listed parcels are being segregated front a larger parcel,are part of 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)
Lot 51, 52, and 53, Block 4, Trails End Homesites, Inc., as per plat recorded in Volume 3 of Plats, page 30, records of
Jefferson County, Washington.
Situate in the County of Jefferson, State of Washington.
MI Select Land Use Code(s): 7. List all personal property(tangible and intangible)included in selling
II
price.
Enter any additional codes:
(See back of last page tbr instructions)
Was the seller receiving a property tax exemption or YES NO
deferral under chapters 84.36,84.37 or 84.38 RCW
(nonprofit organization,senior citizen,or disabled person,
0 Z
homeowner with limited income)?
6.
YES NO
Is this property designated as barest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption:
RCW? 0 El
Is this property classified as current use(open space,farm and 0
agricultural,or timber)land per chapter 84.34? WAC No.(Section/Subsection) 458-61A-203
Is this property receiving special valuation as historical 0
property per chapter 84.26 RCW? Reason for exemption To separate community property
If any answers arc yes,complete as instructed below.
Type of Document Quit Claim Deed
(I)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE)
NEW OWNER(S): To continue the current designation as forest land or Date of Document April 25,2016
classification as current use (open space, farm and agriculture, or timber)
land,you must sign on(3)below. The county assessor must then determine
if the land transtbrred continues to qualify and will indicate by signing below. Gross Selling Price S
If the land no longer qualities or you do not wish to continue the designation *
or classification,it will be removed and the compensating or additional taxes Personal Property(deduct) S
will be due and payable by the seller or transferor at the time of sale. (RCW Exemption Claimed (deduct) S No
84.33.140 or RCW 84.34.108). Prior to signing (3) below, you may contact
your local county assessor for more information. Taxable Selling Price $
Excise Tax: State $
This land 0 does 0 does not qualify for continuance
• Local S
*Delinquent Interest: State $
Local S
DEPUTY ASSESSOR DATE *Delinquent Penalty S
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY)
NEW OWNER(S): To continue special valuation as historic property, Subtotal $
sign(3)below. lithe new owner(s)do 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 $
(3) OWNER(S)SIGNATURE Total Due S 10.00
PRINT NAME A MINIMUM OF 510.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
11---- I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
/
Signature of i
.
i __
Signature of
-z----- ...
' 1 ,
Grantor or Grantor's Agent -;-'/ r Grantee or Grantee's Agent , _...........-----
Name(print) Betty Julianne . y st, Name(print) Casey 0.Wu :eh
Date&city of signing: Lf i• i It VAN r\st.., (..,3)
Date&city of signing Lf-I a I 20 I S. polo- io 4//J,/rrYD
Perjury: Perjury is a class C felo.y whic.1 is punishable by imprisonment in the state correctional institution for a maximum term of not more than tiVe years,or by
a fine in an amount fixed by the court of not more than five thousand dollars(S5,000.00),or by both imprisonment and fine(RCW 9A.20.020(IC).
REV 84 0001a(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER
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