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REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt
PLEASE TYPE OR PRINT when stamped by cashier.
CHAPTER 82.45 RCW—CHAPTER 458-61A WAC
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED
(See back of last page for instructions)
File No.82165JMM
0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name
I. Name Joan D.Hanon,now according to the application Name Marvin J.Pitts and Mary Beth E.Pitts,husband
for title insurance Joan Elkin,as her separate estate and wife
ce O Mailing Address 1094 SW Depot Ct x L-14 Mailing Address 180 Lone Star Rd
City/State/Zip Port Orchard,WA 98367 City/State/Zip Quilcene,WA 98376
Phone No.(including area code) (360)876-6548 Phone No.(including area code) (208)596-1697
3. Send all property tax correspondence to:❑Same as Buyer/Grantee List all real and personal tax parcel account Listed assessed value(s)
numbers—check box if personal property
Name Marvin J.Pitts and Mary Beth E.Pitts 701 052 004/17143 0 323,790.00
Mailing Address 180 Lone Star Rd Tax A
0
City/State/Zip Quilcene,WA 98376 0
Phone No.(including area code) (208)596-1697 0 fri exp ✓'
® Street address of property: 180 Lone Star Rd,Quilcene,WA 98376 1'
This Property is located in f!ilunincorporated Jefferson County OR within 0 city of Quilcene
0 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)
That portion of the West one-half of the East one-half of the Southeast quarter of the Northwest quarter of Section 5,
Township 27 North, Range 1 West, W.M., lying South of Quilcene-Dabob Highway, now known as Dabob Road.
EXCEPTING THEREFROM Dabob Road.
Situate in the County of Jefferson, State of Washington.
Select Land Use Code(s): 11 7. 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,
homeowner with limited income)?
❑ x
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? 0 x
Is this property classified as current use(open space,farm and
agricultural,or timber)land per chapter 84.34? ❑ x WAC No.(Section/Subsection)
Is this property receiving special valuation as historical
property per chapter 84.26 RCW? x 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 20,2016
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 $ 378,000.00
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
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 $ 378,000.00
This land ❑does 0 does not qualify for continuance Excise Tax: State $ 4,838.40
Local $ 1,890.00
*Delinquent Interest: State $
Local $
DEPUTY ASSESSOR DATE *Delinquent Penalty $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $ 6,728.40
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 $ 6,733.40
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
® I C TIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
Signature Signature of
Grantor orr Grantor's Agent '' j..�� Grantee or Grantee's Agent
Name(print) Joan D.Elkin Name(print) Marvin J.Pitts
Date&city of signing: LA,214 ke 'r� Date&city of signing r •
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
j both imprisonment and fine(RCW 9A.20.020(IC).
1SE ONLY COUNTY TREASURER