HomeMy WebLinkAbout125428 Department of
Revenue te REAL ESTATE EXCISE TAX AFFIDAVIT {
Washington State 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.
I Name: Port Ludlow Associates LLC,a Washington Name: Michael A. Bainter and Lisa M. Bainter, husband and
Limited Liability Company wife
a w
w° Mailing Address 70 Breaker Lane z Mailing Address 351 Anchor Lane
City/State/Zip Port Ludlow,WA 98365 m g City/State/Zip Port Ludlow,WA 98365
Phone No.(including area code) 7 - -5w- L)cL Phone No.(including area code) 425-261-H 1.j1--(
3 Send all property tax correspondence to: I XI Same as Buyer/Grantee List all real and personal property tax parcel account List assessed value(s)
numbers-check box if personal property
Name 968900038
Mailing Address Lism, '7,-78—
City/State/Zip 75 71
Phone No.(including area code) I I
® Street address of property: 351 Anchor Lane, Port Ludlow,WA 98365
This property is located in Port Ludlow
II 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 38 of Ludlow Cove Division 2,as per plat recorded in Volume 8 of Plats, pages 112 through 116, records of
Jefferson County,Washington.Situate in the County of Jefferson,State of Washington.
EMISelect Land Use Code(s): Q List all personal property(tangible and intangible)included in selling
at H p price.
enter any additional codes:
(See back of last page of instructions) YES NO
Was the seller receiving a property tax exemption or deferral X
under chapters 84.36,84.37,or 84.38 RCW(nonprofit
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? I XI
Is this property classified as current use(open space,farm and I I I XI WAC No.(Section/Subsection)
agricultural,or timber)land per Chapter 84.34 RCW?
Is this property receiving special valuation as historical property X Reason for exemption
per chapter 84.26 RCW?
If any answers are yes,complete as instructed below.
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) Type of Document Statutory Warranty 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,you Date'of Document May 13, 2016
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 land no Gross Selling Price $ 519,950.00
longer qualifies or you do not wish to continue the designation or classification,it *Personal Property(deduct) $
will be removed and the compensating or additional taxes will be due and payable Exemption Claimed(deduct) $
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 your local county assessor Taxable Selling Price $
for more information. Excise Tax : State $ :?
This land does does not qualify for continuance. Local $ _
'2 f [= 7S
*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,sign(3) Subtotal $ 9255.11
below. If the new owner(s)does not wish to continue,all additional tax calculated
pursuant to chapter 84.26 RCW,shall be due and payable by the seller or transferor *State Technology Fee $ 5.00
at the time of sale. *Affidavit Processing Fee $
(3)OWNER(S)SIGNATURE Total Due $ 9 u , 11
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
® I CERTIFY UN i. ' ' : TY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of 4'i' �_ Signature of
Grantor or ►. antor's Agent/° jI." \ Grantee or Grantee's Agent
-ffairquiPName(print) "1'. . fintra ��Y1O t'-to Name(print) Michael A.Bainter
Date&city of signing: 51/ S' I CO Ee°rt^Htrdtow ., `� fDate&city of signing: -5-7/7/2 a/.6" Kirkland
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(1 C)).
REV 84 0001a(6/26/14) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER
.-c•- 125.428 *5/20/2016 i16 `:1 - i-i - ' "�
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