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Home My WebLink About125403 Departnwnt of 1 Cevenue ��h , 17c Wostmgron REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt SA- 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,82292JMM ❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name I. Name Loretta Eaton,as her separate estate Name Douglas M.Hubbard and Sidonia I.Diaz-Hubbard, a married couple ce O Mailing Address 211 6th Ave ce w Mailing Address 70 Fleet Dr 7.7 z w City/State/Zip Port Hadlock,WA 98339 m City/State/Zip Port Ludlow,WA 98365 - 17111.''"X v) (7 Phone No.(including area code) (360)774-0687 t7 Phone No,(including area code) (360)437-9776 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 Douglas M.Hubbard and Sidonia I. Diaz-Hubbard 961 800 501/30895 1:154,582,00 Mailing Address 70 Fleet Dr ❑ City/State/Zip Port Ludlow,WA 98365 El Phone No.(including area code) (360)437-9776 El ® Street address of property: 211 6th Ave,Port Hadlock,WA 98339 This Property is located inunincorporated Jefferson County OR within ID city of Port Hadlock El Check box if any of the fisted 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) Lots 1 to 4 inclusive, Block 5, all in the Town of irondale, Division No. 2, as per plat recorded in Volume 2 of Plats on page 129, records of Jefferson County, Washington. Situate in the County of Jefferson, State of Washington. Situated on said premises is one 1971 Marle Mobile Home; 56 x 24; License Number+62162; VIN#00757 131 Select Land Use Code(s): 11 7. List all personal property(tangible and intangible)included in selling price. inter any additional codes: (See hack 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)? x ❑ ® YES NO Is this property designated as forest land per chapter 84.33 if claiming an exemption,list WAC number reason for exemption: RCW? ❑ x is this property classified as current use(open space,farm and agricultural,or timber)land per chapter 84.34? ❑ x WAC No.(Section/Subsection) is this property receiving special valuation as historical property per chapter 84.26 RCW? ID x 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 16,2016 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 $ 75,000.00 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 $ 75,000.00 Excise Tax: State $ 960.00 [his land ❑does ❑does not qualify for continuance Local $ 375.00 *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 $ 1,335.00 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 $ 1,340.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS ® i CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING iS TRUE AND CORRECT Signature of .,. Signature of Grantor or Grantor's Agent O'1 e x ,,, e_,a ' -yc� te/ Grantee or Grantee's Agent Is Pa '2Y7,l .t�. _. Name(print) Loretta Eaton Name(print) Douglas 17...,;rubbar ,jDate&city of signing: 4 .1 , 4V—Vb �aiij Date&city of signing '1 1 I Lp rir- ,Perjury: Perjury is a class C felony which is punishable by imprisonment in the state correctional institution foramaximum 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). REV 84 0001a(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER N 95--- 7555,2 _._25403 3:5/16,:.'2i:316 . e 340 5 O I`-57GR�</ ' �u 05