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HomeMy WebLinkAbout125358 Co l�, 5-°cc) epartme ) C Revenue \\ �S Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT CHAPTER 82.45 RCW—CHAPTER 458-61A WAC when stamped by cashier. THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED (See back of last page for instructions) ❑✓ Check box if partial sale of property If multiple owners,list percentage of ownership next to name. 1111 Name Ross W.Colebrook,Personal Representative of the Name Ross W.Colebrook,an unmarried individual O Estate of Ann J.Colebrook,Deceased(50%) is Mailing Address 123 Martingale Place Mailing Address 123 Martingale Place -0 City/State/Zip Port Ludlow,WA 98365 m ioe City/State/Zip Port Ludlow,WA 98365 Phone No.(including area code) Phone No.(including area code) © List all roe tax correspondence to: Same as Bu er/Grantee List all real and personal property tax parcel account property p ❑ y numbers—check box if personal property List assessed value(s) Name 931900050 n $270,212 Mailing Address n City/State/Zip n Phone No.(including area code) n Street address of property: 123 Martingale Place Port Ludlow This property is located in Jefferson County ❑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) Lot 50,Bayview Village,Division No.3,as per plat recorded in Volume 6 of Plats,pages 130 to 132 inclusive,records of Jefferson County,Washington. Situate in the County of Jefferson,State of Washington. ®Select Land Use Code(s): II List all personal property(tangible and intangible)included in selling �11-Household,single family units I price. enter any additional codes: (See back of last page for instructions) YES NO Is this property exempt from property tax per chapter 0 0 84.36 RCW(nonprofit organization)? YES NO If claiming an exemption,list WAC number and reason for exemption: Is this property designated as forest land per chapter 84.33 RCW? ❑ 0 Is this property classified as current use(open space,fatm and ❑ ❑ WAC No.(Section/Subsection) 458-61A-202( 11 agricultural,or timber)land per chapter 84.34? ` J Reason for exemption Is this property receiving special valuation as historical property 0 ❑✓ Inheritance. No consideration. Certified copy of Letters Testamentary per chapter 84.26 RCW? attached. If any answers are yes,complete as instructed below. (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) Type of Document Personal Representative's Quitclaim Deed NEW OWNER(S):To continue the current designation as forest land or classification as current use(open space,farm and agriculture,or timber)land, Date of Document you must sign on(3)below.The county assessor must then determine if the land transferred continues to uali and will indicate y si b Gross Selling Price $ 0.00 q fy gmingbelow.Ifthe land no longer qualifies or you do not wish to continue the designation or *Personal Property(deduct) $ 0.00 classification,it will be removed and the compensating or additional taxes will Exemption Claimed(deduct) $ 0.00 be due and payable by the seller or transferor at the time of sale.(RCW 84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact Taxable Selling Price $ 0.00 your local county assessor for more information. Excise Tax:State $ 0.00 This land ❑does ❑does not qualify for continuance. ! 0.0050 I Local $ 0.00 *Delinquent Interest: State $ 0.00 DEPUTY ASSESSOR DATE Local $ 0.00 (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) *Delinquent Penalty $ 0.00 NEW OWNER(S):To continue special valuation as historic property, sign(3)below.If the new owner(s)does not wish to continue,all Subtotal $ 0.00 additional tax calculated pursuant to chapter 84.26 RCW,shall be due and *State Technology Fee $ 5.00 payable by the seller or transferor at the time of sale. *Affidavit ProcessingFee $ 5.00 (3) OWNER(S)SIGNATURE Total Due $ 10.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS I CE FY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of /4/ Signature of Grantor or Grantor's Agen Grantee or Grantee's Agent's/A.,- I Name(print) Ross W.Colebrook,PersonalalRepresentative Name(print) Ross W.Colebrook,� Date&city of signing: f-s27--/6 Por!1...u...42/0..),Wq Date&city of signing:'l' 0* 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)). REV 84 000tae(2/28/13) THIS SPACE-TREASURER'S USE ONLY DEPT.OF REVENUE 7.552a::4 1.253!5C S12/20:16 I 16735