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HomeMy WebLinkAbout125459 r '`;ry(� -X- 0CSV �.Cs i 9 $ 73 (/ *Department of venue REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT CHAPTER 82.45 RCW—CHAPTER 458-6 IA 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 partial sale of property If multiple owners,list percentage of ownership next to name SName Carolyn Louise McCammon as nee of the Carolyn Louise a Name David L.and Clare Lisa McCammon,or their sccsrs,as Ttees of se re McCammon Survivor's Trust ua...CONTINUED IN 7 BELOW the David L.MoCamnion Living...CONTINUED IN 7 BELOW _ Ce tal Mailing Address 1850 East Marrowstone Road Mailing Address 1850 East Marrowstone Road VI gi City/State/Zip Nordland WA 9t13,503 en b en re City/State/Zip Nordland WA 98358 Phone No.(including area code) r ' /3' //25/U— Phone No(including area code) —3-7p 21 Send all property tax correspondence to Q Same as Buyer/Grantee List all real and personal property tax parcel account List assessed caluets) numbers-check box if personal property Name — 'e.12766,021333009` f1 309,015 Mailing Address _ / g b I-I __ City/State/Zip - --^.... _. .a ._ fl Phone No.(including area code) n al a ft W ©Street address of property; 1859 FAST MARROWSTONF RD NORDLAND WA 98358 This property is located in Jeffers-on County 0 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) SEE ATTACHED ®Select Land Use Code(s) O List all personal property(tangible and intangible)included in selling it).Household,single famity unit/ I price. enter any additional codes: (cont.from 1 above)...McCammon Family Trust ua 1-29-87as amended or (See back of last page for instructions) restated,as to her undivided 50%interest YES NO (continued from 2 above)...Trust,u/a 8-17-15,as amnd;and David L.and Is this property exempt from property tax per chapter ❑ 0 Clare Lisa McCammon,or their successors in interest,as Ttees of the 84.36 RCW(nonprofit organization)? Clare Lisa McCammon Living Trust,u/a 8-17-2015,as ■ YES NO If claiming an exemption,list WAC number and reason for exemption. !stilts property designated as forest land per chapter 84.33 RCW? 0 ❑i Is this properly classified as erairerst use(open space,farm antI 0 0 WAC No.(Section/Subsection) 458-61A-201(6)(1 I agricultural,or timber)land per chapter 84.34? Reason for exemption Is this property receiving special valuation as historical property 0 0 GIFT per chapter 84.26 RCW? !Tarry answers are yes,complete as instructed below. (1)NOTICE OFCON LNUANCE(FOREST LAND ORCURRENT USE) Type of Document STATUTORY WARRANTY DEED NEW OWNER(S):To continue the current designation as forest land or \ 'j classification as current use(open space,Tann and agriculture,or timber) Date of Document ^J` �\I/v 1� land you must sign on(3)below.The county assessor must then determine Gross Selling Price $ 309,015.00 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) $ 0.00 or classification,it will be removed and the compensating or additional taxes Exemption Claimed(deduct) 5 309,015.00 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 5 0.00 your local county assessor for more information. Excise Tax:.State $ 0.00 This land 0 does 0 does not qualify for continuance. I :00E0 'Local $ 0.00 *Delinquent Interest:State $ 0,00 DEPUTY ASSESSOR DATE Local $ 0.00 (2)NOTICE OFCOMPLIANCE(HISTORIC PROPERTY) *Delinquent Penalty S 0.00 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 5.00 and payable by the seller or transferor at the time of sale. (3) OWNER(S)SIGNATURE *Affidavit Processing Fee $ Total Due $ 10.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX "SEE INSTRUCTIONS likt---- I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOIN41'E Of Signature of Signature of . ' / Grantor or Grantor's Agent .. a' rswrGrantee or Grantee's Agent• .�, ',/yiiHri. it ' Name(print) CAROLYN LOSJISE Oh Trusts Name(pnnt) David L.McCammon&Clare Li. cCamrnon Trustees Date&city of signing 'a n 6L Date&city of signing 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 itnprisounent and fine(RCW 9A.20.020(ICA REV 84 000tae(5/31/I t) THIS SPACE-TREASURER'S USE ONLY COUNTY ASSESSOR ` 5C-) -1' ) 75580'.? 12".1.,59 *5/25/2016 j. '.00* Supe or ent of eve ton Department or Revenue REAL ESTATE EXCISE TAX Misttlat s Tas Sttuon Olympia WA 985144477SUPPLEMENTAL STATEMENT (WAC 455-61A-3114) This form must be submitted with the Real Estate Excise Tax Affidavit(FORM REV 54 0001 A for deeded transfers and Form REV 84 0001B for controlling interest transfers)for claims of tax exemption as provided below.Completion of this form is required for the types of real property transfers listed in numbers 1-3 below.Only the first page of this form needs original signatures. AUDIT:Information you provide on this form is subject to audit by the Department of Revenue. In the event of an audit,it is the taxpayers'responsibility to provide documentation to support the selling price or any exemption claimed. This documentation must be maintained for a minimum of four years from date of sale.(RCW 52 45.100)Failure to provide supporting documentation when requested may result in the assessment of tax,penalties,and interest. Any filing that is determined to be fraudulent will carry a 50%evasion penalty in addition to any other accrued penalties or interest when the tax is assessed. PERJURY:Perjury is a class C felony which is punishable by imprisonment in a 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 ($5,000.00),or by both imprisonment and fine(RCW 9A,20.020(I C)). The persons signing below do hereby declare under penalty of perjury that the following is true(check appropriate statement): • I.DDATE OF SALE:(WAC 458-61 A-306(2)) I,(print name) certify that the_ , (type of instrument),dated ,was delivered to me in escrow by (seller's name).NOTE:Agent named here must sign below and indicate name of firm.The payment of the tax is considered current if it is not more than 90 days beyond the date shown on the instrument.If it is past 90 days,interest and penalties apply to the date of the instrument. Reasons held in escrow Signature Firm Name 2. GIFTS:(WAC 458-6IA-20 I)The gift of equity is non-taxable;however,any consideration received is not a gift and is taxable.The value exchanged or paid for equity plus the amount of debt equals the taxable amount.One of the boxes below must be checked. Both Grantor(seller)and Grantee(buyer)must sign below. Grantor(seller)gifts equity valued at$ 154,508.00 to grantee(buyer). NOTE:Examples of different transfer types are provided on the back.'This is to assist you with correctly completing this form and paying your tax. "Consideration"means money or anything of value,either tangible(boats,motor homes,etc)or intangible,paid or delivered,or contracted to be paid or delivered,including performance of services,in return for the transfer of real property.The term includes the amount of any lien,mortgage,contract indebtedness,or other encumbrance,given to secure the purchase price,or any part thereof,or remaining unpaid on the property at the time of sale."Consideration"includes the assumption of an underlying debt on the property by the buyer at the time of transfer, A. Gifts with consideration 1. D Grantor(seller)has made and will continue to make all payments after this transfer on the total debt of $`. • _and has received from the grantee(buyer)$ (include in this figure the value of any items received in exchange for property).Any consideration received by grantor is taxable. 2. D Grantee(buyer)will make payments on- %of total debt of$ for which grantor(seller) is liable and pay grantor(seller)$ (include in this figure the value of any items received in exchange for property).Any consideration received by grantor is taxable. B. Gifts without consideration 1. ® There is no debt on the property;Grantor(seller)has not received any consideration towards equity. No tax is due. 2. D Grantor(seller)has made and will continue to make 100%of the payments on the total debt of$ and has not received any consideration towards equity.No tax is due. 3. D Grantee(buyer)has made and will continue to make 100%of the payments on total debt of$�. and has not paid grantor(seller)any consideration towards equity.No tax is due. 4. El Grantor(seller)and grantee(buyer)have made and will continue to make payments from joint account on total debt before and after the transfer.Grantee(buyer)has not paid grantor(seller)any consideration towards equity. No tax is due. Has there been or will there be a refinance of the debt?D YES D NO(If yes,please call(360)534-1503 to see if this transfer is taxable).If grantor(seller)was on title as co-signor only,please see WAC 458-41A-215 for exemption requirements. The undersigned acknowledge this transaction may be subject to audit read the above information regarding record-keeping requirements and evasion penalties. / �y Gyp t is SI 'ture Date Grantee's Sign t:e Date LM Grantor's Name(pr nt) G 's „ e i� l�, 3. 0 IRS"TAX DEFERRED”EXCHANGE(WAC458-61A-213) ,I 1,(print name) ,certify that I am acting as an Exchange Facilitator in transferring real property to pursuant to IRC Section 1031,and in accordance with WAC 458-614-213.NOTE:Exchange Facilitator must sign below. Exchange Facilitator's Signature Date Exchange Facilitator's Name(print) For tau assistance.contact your local County Treasurer/Recorder or visit httpl/dor wagov or call(360)534-1503 To inquire about the availability of this document in an alternate format,please call 1-800-647-7706.Teletype(7TY)users may use the Washington Relay Service by calling 711. REV 84 00020(8/13/151 COUNTY ASSESSOR 755809 125459 *5,125/2016 10.00* When recorded return to: Michael Best& Friedrich LLP Attn: Jennifer Meyer 100 East Wisconsin Avenue, Suite 3300 Milwaukee, WI 53202 DOCUMENT TITLE: STATUTORY WARRANTY DEED GRANTOR(S): GRANTEE(S); ABBREVIATED LEGAL DESCRIPTION: ADDITIONAL LEGAL DESCRIPTION ON: CAROLYN LOUISE MCCAMMON, as the Trustee of Carolyn Louise McCammon Survivor's Trust u/a The McCammon Family Trust, dated January 29, 1987, as amended and/or restated, DAVID L. and CLARE LISA MCCAMMON, or their successors, as Trustees of the David L. McCammon Living Trust, dated August 1.7, 2015, as amended and/or restated, and DAVID L. and CLARE LISA MCCAMMON, or their successors, as Trustees of the Clare Lisa McCammon Living Trust, dated August 17, 2015, as amended and/or restated, 1850 East Marrowstone Road Nordland,WA 98358 S33 T30 RIE PAGE(S)2 ASSESSOR'S TAX PARCEL NUMBER(S): 12766,021333009 STATUTORY WARRANTY DEED THE GRANTOR, Carolyn Louise McCammon, as the Trustee of Carolyn Louise McCammon Survivor's Trust u/a The McCammon Family Trust, dated January 29, 1987, as amended and/or restated, for and in consideration of Ten Dollars ($10.00), in hand paid,conveys and warrants: a one-half(1/2) undivided interest in my one-half(1/2)undivided interest to David L. and Clare Lisa McCammon, or their successors, as Trustees of the David L. McCammon Living Trust, dated August 17, 2015, as amended and/or restated, and a one-half(1/2) undivided interest in my one-half(1/2) undivided interest to David L. and Clare Lisa McCammon, or their successors, as Trustees of the Clare Lisa McCammon Living Trust, dated August 17,2015, as amended and/or restated, in the following described real estate, situated in the County of Jefferson, State of Washington: A portion of Government Lot 4 in Section 33, Township 30 North, Range 1 East, W.M., lying east of the Marrowstone County Road, more particularly described as follows: Beginning at a point 514 feet South of the North line of said Government Lot 4, said point intersecting the East right of way line of said County Road;thence Southeasterly along said County Road right of way, 554.90 feet to the TRUE POINT OF BEGINNING FOR THIS DESCRIPTION; thence continuing Southeasterly along said County Road right of way, 101.78 feet; thence South 88°15'17" East 340.92 feet to intersect to the Government Meander line; thence North 18°12' West along said Government Meander line to a point that lies South 88°15'17"East from the point of beginning; then North 88°15'17" West,352.35 feet to the point of beginning. After this transaction: David L. and Clare Lisa McCammon, or their successors, as Trustees of the David L. McCammon Living Trust, dated August 17, 2015 will own a one-quarter (1/4) undivided interest in the subject property, and David L. and Clare Lisa McCammon, or their successors, as Trustees of the Clare Lisa McCanunon Living Trust, dated August 17, 2015 will own a one-quarter (1/4) undivided interest in the subject property. Subject to easements, restrictions, covenants, reservations, conditions, declarations and agreements of record. (Signature page follows.) SIGNATURE PAGE TO STATUTORY WARRANTY DEED Dated as of December 31, 2015. GRANTOR: CAROLYN LOUISE MCCAMMON SURVIVOR'S TRUST U/A THE MCCAMMON FAMILY TRUST, DATED JANUARY 29, 1987 By: u Caroly Louise McCammon,Trustee ACKNOWLEDGMENT STATE OF ��1`�i tOA ) )SS. COUNTY OF de ff„t f ) I certify that I know or have satisfactory evidence that Carolyn Louise McCammon is the person who appeared before me, and acknowledged that she signed this instrument and acknowledged it to be a free and voluntary act for the uses and purposes mentioned in this instrument. Dated: ler / 2 ` , 2016. ' '/ 4 Prin ame. JAcgUe Yr, gfuart NotatY Pao Nota Public in and for the State of Residing at P� T�nSP/zd State Of Washington My appointment is permanent. (expires: Od-ID-ao4' JaCqUelYn Stuart Commission Expires 2-10-19