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Home My WebLink About125407 r --1 t 0 d, ' (0 ' • Department at 1 S ? 'VS-C. lti Revenue Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT CHAPTER 82.45 RCW-CHAPTER 458-6IA WAC when stamped by cashier. THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS OF ALL PAGES ARE FULLY COMPLETED (See back of last page for instructions) Escrow No. 40168216-ERI 0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name. 1 Name Jerome Mills and Louise Mills,a married couple Name Kelli Russell Agodon and Rosendo Agodon,a Mailing Address 8102 120th PL SE married couple . o City/State/Zip Newcastle,WA 98056 ,,, Mailing Address 370 N Beach Dr W z Phone No.(including area code)(206)915-8667 w z City/State/Zip Port Ludlow,WA 98365 1}� m Phone No.(including area code(360)860-1213 3 Send all property tax correspondence to . ame as List all real and personal property tax parcel List assessed value(s) Buyer/Grantee account numbers—checkbox if personal property •�` ^� jn y Name -- 934 800 008 0 2ga I ❑ V��T W' Mailing Address 0 City/State/Zip 0 Phone No.(including area code) 0 1111 Street address of property: 370 N Beach Dr,Port Ludlow,WA 98365 This property is located in 0 unincorporated Jefferson County OR within ity of Port Ludlow ❑Check box if any of the listed parcels are being segregated from another rI,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 Exhibit A attached hereto. 5 Select Land Use Code(s): V 7 List all personal property(tangible and intangible)included in Enter any additional codes: selling price. YF'NO Was the seller receiving a property tax exemption or 0 deferral under chapters 84.36,84.37,or 84.38 RCW(nonpr t organization,senior citizen,or disabled person,homeowner with limited income)? 6 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 WAC No.(Section/Subsection) Is the property classified as current use(open space farm and agricultural or timber)land per chapter 84.34? 0 Reason for exemption Is this property receiving special valuation as historical property per chapter 84.26 RCW? 0 If any answers are yes,complete as instructed below. Type of Document Statutory Warr my Deed (I)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) Date of Document :5 i / I kr NEW OWNER(S):To continue the current designation as forest land or classification as current use(open space,farm and agriculture or timber) Gross Selli g Pric- $429,950.00 land,you must sign on(3)below. The county assessor must then determine *personal Property(deduct) $ it the land transferred continues to quality and will indicate by signing below. If the land no longer qualifies or you do not wish to continue the designation Exemption Claimed(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 Taxable Selling Price $429,950.00 84.33.140 or RCW 84.34.108). Prior to signing(3)below,you may contact Excise Tax: State $ your local county assessor for more information. Local $— — This land 0 does 0 does not qualify for continuance. *Delinquent Interest: State $ DEPUTY ASSESSOR DATE Local $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) *Delinquent Penalty $ NEW OWNER(S): To continue special valuation as historic property, Subtotal $ sign(3)below. If the new owner(s)do not wish to continue,all — additional tax calculated pursuant to chapter 84.26 RCW,shall be due *State Technology Fee $ 5.00 and payable by the seller or transferor at the time of sale. *Affidavit Processing Fee $_ (3)OWNER(S)SIGNATURE Total Due $7658.11 PRINT NAME A MINIMUM FEE OF$10..00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS 11111— ' I CERT ^ _. I • P ALTY OF PERJURY THAT THE FOREGOING IS TRUE A I CORRECT. Signature of ) Signature of ) / Grantor or Grantor's Agen — l- Grantee or Grantee's Agent J` Name(print) tse4cr.......... Name(print) I t VA ,C vtCim Date&city of signing: ‘V1t•P W"" V ti Date&city of signing: 5'' ( tY)- ) Li - a V1 4() 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 live years, or by a fine in an amount fixed by the court of not more than live thousand dollars($5,000.00),or by both imprisonment and fine(RCW 9A.20.020(IC). REV 84 0001 a(a)(6/15/13) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER p755505 1256107 3:5,118/20Rt, • 1 c L4o'1 EXHIBIT "A" LOT 8, BRIDGEHAVEN DIVISION NO. 4, AS PER PLAT RECORDED IN VOLUME 4 OF PLATS, PAGES 79 AND 80, RECORDS OF JEFFERSON COUNTY, WASHINGTON; EXCEPT THAT PORTION WHICH LIES NORTHEASTERLY OF THE SOUTHEASTERLY PROJECTION OF THE SOUTHERLY LINE OF BRIDGEHAVEN DIVISION NO. 2, WHICH BEARS SOUTH 76°21' 07" EAST ALL SITUATE IN THE COUNTY OF JEFFERSON, STATE OF WASHINGTON.