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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 458-61A WAC
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED
(See back of last page for instructions)
File No.58173LS
❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name
1. Name Jeannine L.Bayard,wife of grantee Name Kip L. Lilly,a married man as his separate estate
w O Mailing Address 2160 Iglehart Ave wLtj Mailing Address 30 Baycliff Place
z >- z
City/State/Zip St.Paul,MN 55104m City/State/Zip Port Townsend,WA 98368
t7 Phone No.(including area code) (651)233-7373 c7 Phone No.(including area code) (651)271-7711
3. Send all property tax correspondence to:❑Same as Buyer/Grantee List all real and personal tax parcel account
Listed assessed value(s)
numbers-check box if personal property
Name Kip L.Lilly 938 701 109/25738 CI110,000
Mailing Address 30 Baycliff Place ❑
City/State/Zip Port Townsend,WA 98368 ❑
Phone No.(including area code) (651)271-7711 ❑
® Street address of property: XX Palmer Dr,Port Townsend,WA 98368
This Property is located in❑unincorporated Jefferson County OR within El city of Port Townsend
❑Check box if any of the listed parcels are being segregated from 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)
SEE EXHIBIT"A" ATTACHED HERETO AND MADE A PART HEREOF FOR COMPLETE LEGAL DESCRIPTION
® Select Land Use Code(s): 7. List all personal property(tangible and intangible)included in selling
91 price.
Enter any additional codes:
(See back of last page for 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, ❑
homeowner with limited income)?
6. YES NO
Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption:
RCW? ❑
Is this property classified as current use(open space,farm and
agricultural,or timber)land per chapter 84.34? ❑ WAC No.(Section/Subsection) 458-61A-203 i
Is this property receiving special valuation as historical
property per chapter 84.26 RCW? CI ® Reason for exemption To Separate Community Property
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 April 22,2016
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 transferred continues to qualify and will indicate by signing below. Gross Selling Price S
If the land no longer qualifies or you do not wish to continue the designation *Personal Property(deduct) $
or 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 Exemption Claimed(deduct) $ 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 ❑does DIdoes not qualify for continuance
Local $
*Delinquent Interest: State $
Local $
DEPUTY ASSESSOR DATE *Delinquent Penalty $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $
NEW OWNER(S): To continue special valuation as historic property,
sign(3)below. If the new owner(s)do 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
(.9-
en
y PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
fs
U 'p CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
Signature of __, Signature of
Grantor or Grantor's Agent _.-- cy ) Grantee or Grantee's Agent
Name(print) Jeannine L.Bayard Name(print) Kip L.Lilly
Date&city of signing: � �tQ (Ark- Date&city of signing
1 S/
\ �
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(IC).
REV 84 0001a(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER
EXHIBIT A
Lot 9, Block 11, Cape George Colony Division No. 4, as per plat recorded in Volume 4 of Plats, page 24, records of
Jefferson County, Washington.
Situate in the County of Jefferson, State of Washington.