HomeMy WebLinkAbout125470 t h , vA
Department of
Revenue
Washington State /9%,1
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.
IIIRichard S Klebanow,a married man as his separate
Name Roberta Gaylord,as her separate estate II Name estate
a w
w Mailing Address 545 Hendricks St. r=4
z Mailing Address 271 Arabian Lane
c4 z City/State/Zip Port Townsend,WA 98368 co a City/State/Zip Port Townsend,WA 98368
c,Phone No.(including area code) (360)531-0309 t7 Phone No.(including area code) (360)385-6944
II
Send all property tax correspondence to:❑Same as Buyer/Grantee List all real and personal property tax parcel account List assessed value(s)
numbers—check box if personal property
Name Richard S.Klebanow 964202016 0 $234,274.00
Mailing Address 271 Arabian Lane 0
City/State/Zip Port Townsend,WA 98368 c 3P'Lt 9 ❑
Phone No.(including area code) (360)385-6944 0
0 Street address of property: 309 Eddy Court,Port Townsend,WA 98368
This property is located in❑unincorporated Jefferson County OR within®city of Port Townsend
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)
Lot 6,Parkview Addition Short Plat No.2,as per plat recorded in Volume 5 of Short Plats,page 49 and 50,records of
Jefferson County,Washington.
Situate in the County of Jefferson,State of Washington.
n Select Land Use Code(s): Q List all personal property(tangible and intangible)included in selling
11 price.
enter any additional codes:
(See back of last page for instructions)
YES NO
Is this property exempt from property tax per chapter ❑
Ei
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? 0
WAC No.(Section/Subsection)
Is this property classified as current use(open space,farm and
agricultural,or timber)land per chapter 84.34? ❑ ® Reason for exemption
Is this property receiving special valuation as historical 0
property 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
classification as current use(open space,farm and agriculture,or timber) Date of Document May 9,2016
land, you must sign on (3) below. The county assessor must then
determine if the land transferred continues to qualify and will indicate by Gross Selling Price $ 202,000.00
signing below. If the land no longer qualifies or you do not wish to *Personal Property(deduct) $
continue the designation or classification, it will be removed and the
compensating or additional taxes will be due and payable by the seller or Exemption Claimed(deduct) $ No
transferor at the time of sale. (RCW 84.33.140 or RCW 84.34.108).Prior Taxable Selling Price $ 202,000.00
to signing(3)below,you may contact your local county assessor for more Excise Tax: State $ 2,585.60
information.
This land 0 does 0 does not qualify for continuance. Local $ 1,010.00
*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, Subtotal $ 3,595.60
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 $ 3,600.60
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
ElI CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Signature of
Grantor or Grantor's Agent 4 £ Grantee or Grantee's Agent eseAhligi 5 e
Name(print) Roberta Gaylord Name(print) Richard S.Klebanow
Date&city of signing: * '_„ _ ,,,_ . ,?ate&city of signing: 5-- '(& IG
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(IC)).
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5584 12547`_, ..¢.' 26 f201 .SURER'S USE ONLY COUNTY TREASURER 44
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