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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 ARE FULLY COMPLETED
(See back of last page for instructions)
File No.58132LS
❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name
1. Name Bruce M.Barnes,as his separate estate Name Michael Ray McCormick and Katherine Louise
Spangler,husband and wife
x O Mailing Address 10207 Chain Of Rocks ce w Mailing Address 10207 Chain Of Rock St
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City/State/Zip Eagle River,AK 99577 can a City/State/Zip Eagle River,AK 99577
c7 Phone No.(including area code) (360)301-6236 C7 Phone No.(including area code) (907)694-7019
3. Send all property tax correspondence to: D Same as Buyer/Grantee List all real and personal tax parcel account Listed assessed value(s)
numbers—check box it personal property
Name Michael Ray McCormick 985 209 402/38381 ❑ 264,332
Mailing Address 10207 Chain Of Rock St ❑
City/State/Zip Eagle River,AK 99577 ❑
Phone No.(including area code) (907)694-7019 ❑
® Street address of property: 1803 Walnut St,Port Townsend,WA 98368-3615
This Property is located in❑unincorporated Jefferson County OR within®city of Port Townsend
❑Check box if any of the listed 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 5 and 6, and the Easterly 1/2 of Lot 7, Block 94 of Pettygrove's Second Addition to the City of Port Townsend,
as per plat recorded in Volume 2 of Plats, page 17, records of Jefferson County, Washington.
Situate in the County of Jefferson, State of Washington.
® Select Land Use Code(s): 11 Ell List all personal property(tangible and intangible)included in selling
price.
Enter any additional codes:
(See back 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, Elhomeowner with limited income)?
El
6. YES NO
Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption:
RCW? ❑
Is this property classified as current use(open space,farm and
agricultural,or timber)land per chapter 84.34? ❑ WAC No.(Section/Subsection)
Is this property receiving special valuation as historical
property per chapter 84.26 RCW? ❑ 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 18,2016
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 $ 325,000.00
If the land no longer qualities 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 $ 325,000.00
Excise Tax: State $ 4,160.00
This land ❑does ❑does not quality for continuance
Local $ 1,625.00
*Delinquent Interest: State $
Local $
DEPUTY ASSESSOR DATE *Delinquent Penalty $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $ 5,785.00
NEW OWNER(S): To continue special valuation as historic property,
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 $ 5,790.00
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
UI CERTIFY UNDER PENALT4,Y OF PERJURY THAT THE FOREGOING IS TRUE A 1)CORRECT
Signature of Signature of
Grantor or Grantor's Agent mTH Grantee or G n e's Agent ) r
Name(print) Bruce M.Ba es,/ N� �(� Name(print) "' .' ' McCormick J
Date&city of signing: `�'�//�//(Q r`�M `�/ Tb � Date&city of signing ,7 o' iP 1 LAW C✓IC ;
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(1C).
REV 84 0001 a(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER
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