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>lshrt r,sgotfi 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 multiple owners,list percentage of ownership next to name.
fl Name Jennnifer R(Black)Goldsmith • Name Keith J Goldsmith
wo
wMailing Address 8745 NE 144th Ct w Mailing Address 11825 NE 73rd St
City/State/Zip Kirkland,WA 98034
PO City/State/Zip Kirkland,WA 98033
Phone No.(including area code) (206)819-1890 Phone No.(including area code) (206)999-7206
® Send all propertytax correspondence to:ElSame as Buyer/Grantee List all real and personal property tax parcel account
p y numbers—check box if personal property List assessed value(s)
Name 934200006
0 3 (Q'+ 5`L`
Mailing Address ❑
City/State/Zip n
Phone No.(including area code) n
Street address of property: 440 N Beach Dr.,Port Ludlow,WA 98365
This property is located in Jefferson County
❑Check box if any of the listed parcels are being segregated from a larger parcel.
Legal description of property(if more space is needed,you may attach a separate sheet to each page of the affidavit)
Lot 6 Bridgehaven Div.2,Vol.4, Pg 61-62,In Jefferson County,Washington if more space i
needed,attach
additional
sheets.
Select Land Use Code(s): II List all personal property(tangible and intangible)included in selling
Iii-Household,single family units price.
enter any additional codes:
(See back of last page for instructions)
YES NO
Is this property exempt from property tax per chapter ❑ ❑✓
84.36 RCW(nonprofit organization)?
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? ❑ ❑✓
Is this property classified as current use(open space,farm and 0 ❑✓ WAC No. (Section/Subsection) WAC 458-61A-203(2)
agricultural,or timber)land per chapter 84.34?
Reason for exemption Dissolution of Marriage
Is this property receiving special valuation as historical property ❑ ❑✓ Per Decree 09-3-06765-5 SEA
per chapter 8426 RCW?
If any answers are yes,complete as instructed below.
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) Type of Document Quit Claim Deed
NEW OWNER(S):To continue the current designation as forest land or
classification as current use(open space,farm and agriculture,or timber) Date of Document April 18,2016
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 $
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 Exemption Claimed(deduct) $
will be due and payable 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 Taxable Selling Price $ 0.00
your local county assessor for more information. Excise Tax: State $ 0.00
This land 0 does ❑does not qualify for continuance. 0.0050 Local $ 0.00
*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)below.If the new owner(s)does not wish to continue,all Subtotal $ 0.00
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.
(3) OWNERS)SIGNATURE
*Affidavit Processing Fee $ 10.00
Totalf 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 .1 Signature of
Grantor or Grantor's Agen4. El I a�- 4 s j4'�{a antee or Grantee's Age
Name(print) Jennifer R(Black)Goldsmith \ / Name(print) Keith J Goldsmith
Date&city of signing: 5/Q,/i G • r.,_ kt.n Date&city of signing: Z ,72K +D
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 0001ae(a)(05/08/07) THIS SPACE-TREASURER'S USE ONLY DEPT;�C RE`
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