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Home My WebLink About125460 Department of tal Revenue Washington State 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. A Name MA M IG1 L. CKev © Name zi(»e,` 5 e"LI C.V W LsAYY�111 '�'k- , CC--lr 10 W° 7,D 1x 0V-tOU 1W V C a Z Mailing Address) z Mailing Address» t CKei� J� City/State/Zip `j t'� — U.�1L-,C) ..v}7 -!r 'lQ , m g City/State/Zip PGY"- L C110t� IL-04 q ,_'\IP Phone No.(including area code)_,_ Phone No.(including area code) (,✓)cO 38 9-7 S-9 Sr List all real and personal property tax parcel account ® Send all property tax correspondence to:l me as Buyer/Grantee List assessed value(s) n mbers—check box if personal property Name .4 5( .... 1 1J1'�-S- --0 Q 6 &r)1P2- Mailing Address n City/State/Zip D Phone No.(including area code) ri © Street address of property: This property is located in Jefferson County ❑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) (:_kkacjik.t.cA IIISelect Land Use Code(s): I I 0 List all personal property(tangible and intangible)included in selling Select Land Use Codes price. enter any additional codes: (See back of last page for instructions) YES NO Was the seller receiving a property tax exemption or deferral under ❑ ✓❑ chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? © 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? 0 ❑✓ WAC No. (Section/Subsection) Is this property classified as current use(open space,farm and 0 ❑✓ agricultural,or timber)land per chapter 8434 RCW? Reason for exemption Is this property receiving special valuation as historical property 0 0 per chapter 84.26 RCW? If any answers are yes,complete as instructed below. Type of Document C. ftse (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) f �� NEW OWNER(S):To continue the current designation as forest land or Date of Document classification as current use(open space,farm and agriculture,or timber)land, I you must sign on(3)below.The county assessor must then determine if the Gross Selling Price $ 1 � � land transferred continues to qualify and will indicate by signing below.If the *Personal Property (deduct) $ land no longer qualifies or you do not wish to continue the designation or Exemption Claimed (deduct) $ 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 Taxable Selling Price $ 0.00 84.33.140 or RCC1.84.34.108).Prior to signing(3)below,you may contact Excise Tax : State $ 12c) 0.00 your local county assessor for more information. 0.0050 Local $ 1 . 0.00 This land ❑does ❑does not qualify for continuance. *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) 1/"� NEW OWNER(S):To continue special valuation as historic property, Subtotal $ e ( :10 0.00 sign(3)below.If the new owner(s)does 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 $ 3i Ti b .10 n0 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS flI CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of SignGrantee o , - - n , Grantor or Grantor's Agent Grantee or Grantee's Ag �'-�4�- Name(print) Name(print) !)Ji /NJ I CL .,..3 6rYt C-E. Date&city of signing: Date&city of signing: :37Z.57 /`o e0g-r- -roc°tis e 0 U 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 tine in an amount fixed by the court of not more than five thousand dollars($5,000.00),or by both imprisonment and fine(RCVN/9A.20.020(IC)). REV 84 0001a(01/04/16) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER 'C)0 ic/"1 AFTER RECORDING RETURN TO: Daniel Semler Estrellita DeCarlo 171 Dickey Street Port Ludlow WA 98365 EASEMENT The GRANTOR, RONALD L. MICKENS, of 190 Dickey Street, Port Ludlow, WA 98365, for and in consideration of One Thousand Five Hundred Dollars ($1,500.00) in hand paid, grant and convey to the GRANTEES, DANIEL SEMLER and ESTRELLITA D. DECARLO, of 171 Dickey Street, Port Ludlow, WA 98365, a non-exclusive easement for the partial placement of a 10ft. x 12ft. studio and an 8ft. x 8ft. garden shed, which easement shall measure seven feet (7') wide and sixty feet (60') long and shall commence at the west boundary of the county road and run 60' along Grantor's parcel line west as illustrated on Exhibit A attached hereto on the following described real estate: Lots 21 and 22 in Block 12 and Lots 1 and 2 in Block 13 of Second Addition to Trail's End Homesites, Inc. as per plat recorded in Volume 4 of Plats, on Page 1 Records of Jefferson County, Washington. Which easement shall run with the land and benefit the following described real estate: LOT 3, Block 13, Second Addition to Trail's End Homesites, Inc., as per plat recorded in Volume 4 of Plats, page 1 records of Jefferson County, State of Washington. Dated this 23 day of May 2016. 4t R ALD L. I ENS EASEMENT -Page 1 of 2 STATE OF WASHINGTON ) ss COUNTY OF JEFFERSON ) ON THIS i3day of May 2016, before me, personally appeared RONALD L. MICKENS, to me known to be the individual who executed the within and foregoing instrument, and acknowledged said instrument to be his free and voluntary act and deed, for the uses and purposes therein mentioned. WITNESS my hand and official seal hereto the day and year in this certificated first written above. ,,,, .. Public'.,. Notary State of Washington ( MICHELLE SHANNON Notary Public in and for the State of MY COMMISSION EXPIRES Washington, p Decembers,2019 Residing at ti-t-561., f 446/cad' My Appointment Expires /. G' l— .20/c/. EASEMENT-Page 2 of 2 e . t -.:-,14 0 EXHIBIT A Va k eC?5 n.e 4 0 ,_ ± cv Vii \ _. , k� -s ri ----• f it alp 1.1 ti � -Ni .�, ,)I I , N. i y'I { \ , ii1i; K ' 11 0 j 1 O i ---.1{ iN Eq 1J, ` , L4.1 A-4,,,.. v f k vu " , i J I 7e-0f .,,--. ell _ \ (th;� . �� '. ..114 ‘'*‘: