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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.58007RW
❑Check box if partial sale of property if multiple owners,list percentage of ownership next to name
1. Name Donald C.Smith,as his separate estate 2. Name Patrick J.Johnson and Peg Hunter,husband and
wife
O Mailing Address 4701 7th Ave SW,Apt 103 w H Mailing Address 4662 Kat Lane
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w City/State/Zip Olympia,WA 98502 City/State/Zip Port Townsend,WA 98368
c7 Phone No.(including area code) (360)866-3908 Phone No,(including area code) (406)461-8557
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 Patrick J.Johnson 951 902 608/29177 ❑
261,614
Mailing Address 4662 Kat Lane ❑
City/State/Zip Port Townsend,WA 98368 ❑
Phone No.(including area code) (406)461-8557 ❑
fl Street address of property: 4662 Kat Lane,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)
Lot F of survey of Lots 6 through 15, Block 26, Plat of Fowlers Park Addition to the City of Port Townsend, recorded
in Volume 2, page 16, of Plats, records of Jefferson County, Washington, said survey recorded July 21, 1998 in
Volume 20 of Surveys, page 21, records of Jefferson County, Washington.
Situate in the County of Jefferson, State of Washington.
Select Land Use Code(s): 11 0 List all personal property(tangible and intangible)included in selling
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)? ❑
El
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)
Is this property receiving special valuation as historical
El ®
property per chapter 84.26 RCW? Reason for exemption
If any answers are yes,complete as instructed below.
Type of Document Statutory Warranty 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 May ,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 $ 335,000.00
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 $ 335,000.00
Excise Tax: State $ 4,288.00
This land ❑does E does not qualify for continuance
Local $ 1,675.00
*Delinquent Interest: State $
Local $
DEPUTY ASSESSOR DATE *Delinquent Penalty $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $ 5,963.00
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 $ 5,968.00
PRiNT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
UI CERTIFY UNDER PENA TY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
9
Signature of / �!/77, Signature of
Grantor or Grantor's Agent 1�a y . w ``��Lj'C .( Grantee or Grantee's Agent
Name(print) Donald C.Smith Name(print) Pa5rick— JOh,nson
Da/te&city�f Signing: y �C�1 Date&city of sign ig /c., %- c� 6Pe jtury: l jury ts'I`clLs C Felony which is punishable by imprisonment in the state correctional institution for a ma;'nui erm of not more than 11,' y r' ea s,'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).
COUNTY TREASURER
755275 1 353 *5/1.1/2016 96.00* 1 ic725�