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HomeMy WebLinkAbout125417 Department of t-`} L(t )re. Revenue 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 multi)le owners,list percentage of ownership next to name. fl Name 9��1 � 1-y�V,i`WYk(1N'it ne.\i7YlC 0 © Name 4 V1 () ;j,4-C{+ 1 t rr pe o \<uloWvt Or.S `JoseS C.V1r;( ;,0Va ZY1 . W '4)z.,„„66,---.,Ess- az Mailing Address t) 2-- �" ro � "� z Mailing Address y 7 e r2, tf rip City/State/Zip 7 �� t�G� '''o ci) City/State/Zip �C` 1:+Lel--/`1,/, � e f 1 333 CD Phone No.(including area code) .34'0 r 5-5/ ' (Z4/1-74Phone No.(including area code) -- e 2-2-Z —4/13 5-- ® Send all property tax correspondence to: List all real and personal property tax parcel account p p y p ane as Buyer/Grantee numbers-check box if personal property List assessed value(s) Name Mailing Address 1 ❑ U q ` a5D City/State/Zip ❑ Phone No.(including area code) 3'y 5a a ❑ pStreet address of property: N., Q1T3 ,- -r %:j"'/ F(l/Li-- .10 t,,1, . (s►!,)This property is located in unincorporated 'C ,e c- -Q,rS \d-N County OR within❑city of ❑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) r , p# i, /,S" 0 4-7 U .40 P / 71 to ) t t . Z-® Li,-r-' / iLUG1d # i 2— 1 PrAil C.,4-4./e.01._ 57/-67t-/E-W_S- ,41/7-e- 4 bj- a-rA. -4* O 6 °- du66:5--—8 ® Select Land Use Code(s): OL 111 List all personal roperty(tangible and intangible)included in selling price. Alt;t Jl a 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 0 chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? ® 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? ❑ WAC No. (Section/Subsection) . Is this property classified as current use(open space,farm and 0 131 --- agricultural,or timber)land per chapter 84.34 RCW? R :son for exemption Is this property receiving special valuation as historical property 0 U.l' per chapter 84.26 RCW? If any answers are yes,complete as instructed below. Type of Document aC AD (1)NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) j NEW OWNER(S):To continue the current designation as forest land or Date of Document ( i .c/ ( 4 classification as current use(open space,farm and agriculture,or timber)land, g / r0i 00 0 you must sign on(3)below.The county assessor must then determine if the Gross Sellin Price $ 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.(RCW Taxable Selling Price $ 53 0 1 no 84.33.140 or RCW 84.34.108).Prior to signing(3)below,you may contact yourC- county Excise Tax : State $_ •� \ 1 O„aq ✓ local assessor for more information. Local $ L100 This land ❑does ❑does not qualify for continuance. *Delinquent Interest: State $ q,Si Local $ DEPUTY ASSESSOR DATE • '�}} *Delinquent Penalty $ moi% ,SO (2) NOTICE OF COMPLIANCE(HISTORIC PROPERTY) NEW OWNER(S):To continue special valuation as historic property, Subtotal $ 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 84.26 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 $ 1V1 a3 .573 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 D ORRECT. Signature of g Signature of ✓._ 1 , Alir / Grantor or Grantor's , t t AV f 0 , /Q L4-- t _- Grantee or Grantee's Agent �''- Arucilmatif Name(print) ♦ 6 ' ' .J--G--1 _ Name(print) - i /P (6C t s Date&city of signing: PO 'LT- ' /t 44//"- A/ -5 4 Date&city of signing: 6I /2-7 %J iv Er'oa Am 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)). REV 84 0001a(6/26/14) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURE'4 i . .._.. _ 2_41 1 ,72 /_... .