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Sase REAL ESTATE EXCISE TAX AFFIDAVIT This form is your Y�qe tl`11"a
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)
0 Check box if sartial sale of.ro e If multi.le owners list.ercenta_e of ownershi.next to name.
Name Peter Guerin and Kimberly Guerin, 2 ; Name Stephen J. Ohnstad and Janet M.
Husband and Wife Ohnstad, Husband and Wife
w z Mailing Address 10919 47th Ave SE w H Mailing Address 728 Hogback Rd.
City/state/zip Everett, WA 98208 City/State/Zip Sequim, WA 98382
Phone No.(includingarea (425) 232-7739
code) Phone No.(including area code) (360) 683-2734
gSend all property tax correspondence to: Same as Buyer/Grantee List all real and personal property tax parcel account
p p y p y numbers-check box if personal property List assessed value(s)
Name 936 000 205 1=1 32,400
Mailing Address ❑
City/State/Zip �� ❑
Phone No.(including area code) ❑
Street address of property:
This property is located in a.unincorporated Jefferson 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)
Lot 5, Block 2, Brinnonwold, as per plat recorded in Volume 4 of Plats,
pages 77 and 78, records of Jefferson County, Washington.
13 Select Land Use Code(s): 91 ® List all personal property(tangible and intangible)included in selling
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)?
0, 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 ❑ [XJ WAC No. (Section/Subsection)
agricultural,or timber)land per chapter 84.34? Reason for exemption
Is this property receiving special valuation as historical property ❑ IA
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 /Z�/�s
classification as current use(open space,farm and agriculture,or timber) Date of Document l ( �Ci
land,you must sign on(3)below.The county assessor must then determine Gross Selling Price $ 39,000.00
if the land transferred continues to qualify and will indicate by signing below.
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 $
your local county assessor for more information. Excise Tax : State $ 499.20
This land ❑does ❑does not qualify for continuance. Local $ 195.00
*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 $ b , f(�
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) OWNER(S)SIGNATURE *Affidavit Processing Fee $
Total Due $ 699.20
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 AND CORRECT.
Signatre of ` , �`��� Signature of l(^,�� 1_„�
Grantor or Grantor ��Q P I/�-•"7� Grantee or Gra ee's Agent (yam 'tet
+� / l
�/Q `�
Name(print) � G�w ��. �, (� rp,s j,s�--
r Name(print) —�" �i'HC-a-C {
Date&city of signing: 5.12 ` ' 011/01-411 Date&city of signing: Z2444411 k N^iii4j "s4.
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)).
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