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Revenue •
Washington State 65 b C),71
REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt .
EASE TYPE OR PRINT 2 -i ds s`k
�'L CHAPTER 4,_ #.� IZ(:'W-CHAPTER�4:"i;-(��I � WAC' when stamped by cashier.
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED
(See back ol'last page for instructions)
0 Check box if artial sale of rosert If multi.le owners,list .ercenta'e ofownershi. next to name.
Name Jamie Senske 2 Name Jamie Senske and Kimberly Starr, Joint tenants
cC. w
with ri_aht of survivorship
z Mailing Address PO Box 222 z Mailing Address PO Box 222
City/State/Zip Quilcene. WA 98376 city/state/zip Quilcene, WA 98376
Phone No.(including area code)(360) 620-1709 Phone No.(including area code)(360) 979-6273
III Send all property tax correspondence to:❑✓ Same as Buyer/Grantee List all real and personal property tax parcel account List assessed value(s)
numbers—check box if personal property
Name 702 131 026 0 $45,750.00
Mailing Address TA/ 13 S l PCa"C e (A n
City/State/Zip n
Phone No.(including area code) n /i rey 1,/
Street address of property: 13934 Center Road,Quilcene,WA 98376
This property is located in Jefferson County
0 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)
Parcel 6 of survey recorded January 2, 1979, in Volume 3 of Surveys,page 2, under Auditor's File No.254969, records of Jefferson
County,Washington;
Being a portion of the Northeast 1/4 of the Northeast 1/4 of Section 13,Township 27 North, Range 2 West,W.M.
Situate in the County of Jefferson,State of Washington.
11"
Select Land Use Code(s): 111 List all personal property(tangible and intangible)included in selling
91-Undeveloped land(land only) 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
c iapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior
citizen,or disabled person,homeowner with limited income)?
6 If claiming an exemption, list WAC number and reason for exemption:
YES NO
Is this property designated asforestland per chapter 8,1331tC.A ? 0 0 WAC No. (Section/Subsection) 458-61A-;av\ 3
Is this property classified as current use(open space,farm and ❑ ❑✓
agricultural,or timber)land per chapter 84.34 RC'l1? Reason for exemption
Creation of Joint Tenancy(with right of survivorship)/Gift
Is this property receiving special valuation as historical property 0 0
per chapter 84.26 RCW?
If any answers are yes,complete as instructed below. Type of Document Quit Claim Deed
O NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE)
NEW OWNER(S):To continue the current designation as forest land or Date of Document 5111 I�r
classification as current use(open space,farm and agriculture,or timber)land, Gross Selling Price $ 0.00
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) $ 0.00
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.(RCW Taxable Selling Price $ 0.00
84.33.140 or R('W 8 .34.108).Prior to signing(3)below,you may contact Excise Tax : State $ 0.00
your local county assessor for more information. 0.0050 Local $ 0.00
This land 0 does 0 does 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 84.2.6 R('W 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$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRIjCTIONS
I CERT!+ UNDERr••"r'OF PERJURY THAT THE FOREGOING IS TRUE AND CORI i
Signature of Signature of ��►�. �'�
Grantor or Grantor' /- Grantee or Grantee's Age %EWA�
Name(print) Jamie - a' • Name(print) Jamie Sen ;Cgs:- bow
Date&city of signing:c-il— ULU(C.elne: Date&city of signing: 6`17-Ito Qi In.jj evq,
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)).
THIS SPACE-TREASURER'S USE ONLY COUNTY TREAS,R .
11614(Y .
cr
State of Washington REAL ESTATE�EXCISE TAX
epartment of Revenue
MDiscellaneous Tax Section SUPPLEMENTAL STATEMENT
....,.,
PO Box 47477
Olympia WA 98504-7477 (WAC 458-61A-304)
This form must be submitted with the Real Estate Excise Tax Affidavit(FORM REV 84 0001A for deeded transfers and
Form REV 84 0001B for controlling interest transfers)for claims of tax exemption as provided below.Completion of this form is
required for the types of real property transfers listed in numbers 1-3 below.Only the first page of this form needs original signatures.
AUDIT:Information you provide on this form is subject to audit by the Department of Revenue. In the event of an audit,it is the
taxpayers' responsibility to provide documentation to support the selling price or any exemption claimed. This documentation
must be maintained for a minimum of four years from date of sale.(RCW 82.45.100)Failure to provide supporting documentation
when requested may result in the assessment of tax,penalties,and interest. Any filing that is determined to be fraudulent will carry a
50%evasion penalty in addition to any other accrued penalties or interest when the tax is assessed.
PERJURY:Perjury is a class C felony which is punishable by imprisonment in a 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
($5,000.00),or by both imprisonment and fine(RCW 9A.20.020(1C)).
The persons signing below do hereby declare under penalty of perjury that the following is true(check appropriate statement):
1.El DATE OF SALE: (WAC 458-61A-306(2))
I,(print name) certify that the
(type of instrument),dated ,was delivered to me in escrow by
(seller's name).NOTE:Agent named here must sign below and indicate name of firm.The payment of the tax is considered current if
it is not more than 90 days beyond the date shown on the instrument.If it is past 90 days,interest and penalties apply to the date of the
instrument.
Reasons held in escrow
Signature Firm Name
>. GIFTS:(WAC 458-61A-201)The gift of equity is non-taxable;however,any consideration received is not a gift and is taxable.The
value exchanged or paid for equity plus the amount of debt equals the taxable amount.One of the boxes below must be checked.
Both Grantor(seller)and Grantee(buyer)must sign below.
Grantor(seller)gifts equity valued at$ to grantee(buyer).
NOTE: Examples of different transfer types are provided on the back.This is to assist you with correctly completing
this form and paying your tax.
"Consideration"means money or anything of value,either tangible(boats,motor homes,etc)or intangible,paid or delivered,or
contracted to be paid or delivered,including performance of services,in return for the transfer of real property.The term includes the
amount of any lien,mortgage,contract indebtedness,or other encumbrance,given to secure the purchase price,or any part thereof,or
remaining unpaid on the property at the time of sale."Consideration" includes the assumption of an underlying debt on the property
by the buyer at the time of transfer.
A. Gifts with consideration
1. ❑ Grantor(seller)has made and will continue to make all payments after this transfer on the total debt of
$ and has received from the grantee(buyer)$
(include in this figure the value of any items received in exchange for property).Any consideration received by
grantor is taxable.
2. ❑ Grantee(buyer)will make payments on %of total debt of$ for which grantor(seller)
is liable and pay grantor(seller)$ (include in this figure the value of any items received in
exchange for property).Any consideration received by grantor is taxable.
B. Gifts without consideration
1. ❑ There is no debt on the property;Grantor(seller)has not received any consideration towards equity.
No tax is due.
2. ❑ Grantor(seller)has made and will continue to make 100%of the payments on the total debt of$
and has not received any consideration towards equity.No tax is due. 22 -�a
3. Lg Grantee(buyer)has made and will continue to make 100%of the payments on total debt of$ J•.�3 ,
and has not paid grantor(seller)any consideration towards equity.No tax is due.
4. 0 Grantor(seller)and grantee(buyer)have made and will continue to make payments from joint account on total
debt before and after the transfer. Grantee(buyer)has not paid grantor(seller)any consideration towards equity.
No tax is due.
Has there been or will there be a refinance of the debt? ❑ YES CS NO(If yes,please c. •1 ,-1503 to see if this transfer is
taxable).If grantor(seller)was o ' co-signor only,please se t AC 458-. ,s, o exemptlsn requ .ements.
The undersigned ackno. _* ansaction may be subject a 4e information regarding
ecord-keeping re. . .-' nd evasion penalties.
2
a... —I, - # . ....�-- S--/8'-/e
4011:,• y ature - Date `r antee's Signature Date
t volt. f ' A .• u • _/ A "
Grantor's Name(print) Grantee'. .AL; .rint)
3. ❑ IRS"TAX DEFERRED"EXCHANGE(WAC 458-61A-213) 'R��` fes\
I,(print name) ,certify that I am acting .• an Exchange Facilitator in transferring real property
,R to pursuant to IRC Section 1031,and in accordance with WAC 458-61A-213. NOTE: Exchange
, Facilitator must sign below.
Exchange Facilitator's Signature 8(6...tec5 s)61'1'afi^'''k,
For tax assistance,contact your local County Treasurer/Recorder or visit http://dor.wa.gov or call(360)534-1503. To inquire about the availability of this document in
..n an alternate format,please call 1-800-647-7706.Teletype(TTY)users may use the Washington Relay Service by calling 711.
A
,; REV 84 0002ea(6/26/14) COUNTY TREASURER