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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.58012RW
❑Check box if artial sale of property If multiple owners,list percentage of ownership next to name
1. Name J.Phillip Hughes and Cecilia Hughes,husband and Name William George Palsulich and Nancy C.Palsulich,
wife husband and wife
W O Mailing Address 2390 Tekiu Point Rd NW w LLI Mailing Address 534 Woodridge Dr
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w City/State/Zip Seabeck,WA 98380 m City/State/Zip Port Ludlow,WA 98365
c7 Phone No.(including area code) (360)830-0506 Phone No.(including area code) (720)999-3049
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 William George Palsulich 999 700 027/44052 1=1401,397
Mailing Address 534 Woodridge Dr ❑
City/State/Zip Port Ludlow,WA 98365 ❑
Phone No.(including area code) (720)999-3049 ❑
�Street address of property: 534 Woodridge Dr,Port Ludlow,WA 98365
This Property is located in El unincorporated Jefferson County OR within❑city of Port Ludlow
❑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)
Lot 27, Woodridge Village Division 1, as per plat recorded in Volume 7 of Plats, pages 47 through 50, records of
Jefferson County, Washington.
Situate in the County of Jefferson, State of Washington.
® Select Land Use Code(s): 0 List all personal property(tangible and intangible)included in selling
11 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)? ❑
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 andEI '1~' j
agricultural,or timber)land per chapter 84.34? WAC No.(Section/Subsection)
Is this property receiving special valuation as historical
property per chapter 84.26 RCW? ❑ Reason for exemption
If any answers are yes,complete as instructed below.
Type of Document Statutory Warranty Deed
(l)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE)
NEW OWNER(S): To continue the current designation as forest land or Date of Document April 18,2016
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 $ 452,000.00
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 $ 452,000.00
Excise Tax: State $ 5,785.60
This land ❑does ❑does not qualify for continuance
Local $ 2,260.00
*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 $ 8,045.60
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 $ 8,050.60
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
1111-- I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
Signature of - gSi nature of
ji,„„Ae,
Grantor ra n torls-Aien t �: �� Grantee o rantee's nth,/
Name(print) J. ' es i let"-t"- Name(print) e. S
Date&city of signing: _ ?I y5 if 'J�r te- Date&city of signing ► al.21PM
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(1C).
COUNTY TREASURER
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