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HomeMy WebLinkAbout125354 T 1 ' - r Department ofU ) Revenue C Washington State REAL ESTATE EXCISE TAX AFFIDAVIT �" This form yourreceipt PLEASE TYPE OR PRINT CHAPTER K24 5 RCW—CHAPTER 455-61A WAC when stamped by cashier. THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED ii\Yt (See back of last page for instructions) ❑ Check box if partial sale of property If multiple owners,list percentage of ownership next to name. ''lV'V\M 0 Name Fidelity National Title Insurance Comoanv © Name Umoaua Bank a o E d r11,Y/_f ri'' Vy'i5rne;S 2 .tia Mailing Address 11000 tSlson Drive.Suite 101 Mailing Address One SW Columbia Street.Suite 1400 v,,6 City/state/zip Rancho Cordova CA 95670 m City/State/Zip Portland,OR 97258 Phone No.(including area code)(916)636-01 14 Phone No(including area code)(503)727-4205 © Send all roe tax correspondence to- Same as Bu eriGrantee List all real and personal property tax parcel account property nY P ❑ Y List assessed vi ue(s) numbers—check box if personal pro erty ��J Name 902-251-003 LZ 2 n I-r7 lob (.�1, Mailing Address 907-251-005 2-Z n L. - -.�, 0-1-7 City/State/Zip 902-251-006 ZZF I I n p ._i . Phone No.(including area code) 902-251-007 ?Z 15 n 1®3/5- / j jir5- MIStreet address of property Vacant Land This property is located in Port Townsend ❑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) SEE ATTACHED Select Land Use Code(s):II:! List all personal property(tangible and intangible)included in selling ss-Other undeveloped i,'ii I III price. enter any additional codes: (See back of last page for instructions) YES NO Was the seller receiving a property tax exemption or deferral under 0 chapters 54 36,8437,or 84.38 RCA'(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? MIYES NO If claiming an exemption,list WAC number and reason for exemption. Is this property designated as forest land per chapter 8433RCW? 0 0 WAC No.(Section/Subsection) 458-61A-208(4) Is this property classified as current use(open space,farm and 0 0 agricultural,or timber)land per chapter 84 54 Ri'\I7 Reason for exemption Foreclosure-grantee is foreclosing lender Is this property receiving special valuation as histoncal property ❑ 0 per chapter 84.26 RCW? If any answers are yes,complete as instructed below. Type of Document TDUS (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) NEW OWNER(S):To continue the current designation as forest land or Date of Document 4/6/16 classification as can-eat use(open space,farm and agriculture,or timber)land, Gross Selling Price $ 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.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.(I-CY Taxable Selling Price $ 0.00 84.3.3 140 or RCW 5434.1(A).Prior to signing(3)below,you may contact Excise Tax:State $ 0.00 your local county assessor for more information. 0.0050 J Local $ 0.00 This land 0 does 0does not qualify for continuance. *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 $ 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 S4 20 RCH,shall be due and payable by the seller or transferor at the time of sale. *Affidavit Processing Fee $ 5.00 (3) OWNER(S)SIGNATURE Total Due $ 10.00 PRINT NAME A MINIMUM OF 510.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS III CERT Y UNDER PENAL OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of t j �� azure of Grantor or Grantor's Agent -4/1--q.%'� `"L Grantee or Grantee's Agent Name(print) Sara Berens Name(print) Jenny Taylor Date&city of signing: 4/6/16,Rancho Cordova,CA Date&city of signing: 4/6/16, Ran o Cordova,CA c,a Perjury:Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a maximurn term of not more than five years,or by Iv a fine in an amotmt fixed by the court of not more than five thousand dollars($5,000.00),or by both imprisonment and fine(RCW 9.\20 021(1/C)). t= Cl REV 84 000ba(05/21/IS) THIS SPACE-TREASURER'S USE ONLY COUNTY T ASU ER 1 Z�#14f LEGAL DESCRIPTION PARCEL A: .16?z51003 THE NORTH 1/2 OF THE NORTHEAST 1/4 OF THE NORTHEAST 1/4 OF SECTION 25, TOWNSHIP 29 NORTH, RANGE 2 WEST, W.M., JEFFERSON COUNTY, WASHINGTON. PARCEL B: 14-902,2,5 JOG 5 THE SOUTH 1/2 OF THE NORTHEAST 1/4 OF THE NORTHEAST 1/4 OF SECTION 25, TOWNSHIP 29 NORTH, RANGE 2 WEST, W.M., JEFFERSON COUNTY, WASHINGTON. PARCEL C: goo z 5'10 c Y THE NORTH 1/2 OF THE NORTHWEST 1/4 OF THE NORTHEAST 1/4 OF SECTION 25, TOWNSHIP 29 NORTH, RANGE 2 WEST, W.M., JEFFERSON COUNTY, WASHINGTON. PARCEL D: # 7O2 7 0 7 THE SOUTH 1/2 OF THE NORTHWEST 1/4 OF THE NORTHEAST 1/4 OF SECTION 25, TOWNSHIP 29 NORTH, RANGE 2 WEST, W.M., JEFFERSON COUNTY, WASHINGTON. ALL SITUATE IN THE COUNTY OF JEFFERSON, STATE OF WASHINGTON