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Home My WebLink About125471 Depart nt oft Revenue Wr sh ngton 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) 0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name. NRichard S Klebanow,a married man as his separate Name Tana Klebanow M Name estate Wife of Grantee aa Mailing Address 271 Arabian Lane r u. Mailing Address 271 Arabian Lane a City/State/Zip Port Townsend,WA 98368 R a City/State/Zip Port Townsend,WA 98368 cn L Phone No.(including area code) 360-385-6944 t7 Phone No.(including area code) (360)385-6944 III 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& Tana Klebanow 964202016 0 217,737.00 Mailing Address 271 Arabian Lane 0 City/State/Zip Port Townsend,WA 98368 ` H ❑ Phone No.(including area code) (360)385-6944 ❑ ®Street address of property: 309 Eddy Court,Port Townsend,WA 98368 This property is located in 0 unincorporated Jefferson County OR within®city of Port Townsend ❑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. ® 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 ❑ 84.36 RCW(nonprofit organization)? UYES 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) 458-61A-203(1) Is this property classified as current use(open space,farm and agricultural,or timber)land per chapter 84.34? ❑ ® Reason for exemption To establish separate property Is this property receiving special valuation as historical 0 El 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 Quit Claim 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 13,2016 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 $ 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) $ transferor at the time of sale. (RCW 84.33.140 or RCW 84.34.108).Prior Taxable Selling Price $ to signing(3)below,you may contact your local county assessor for more Excise Tax: State $ information. This land 0 does 0 does not qualify for continuance. Local $ *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 $ sign (3) below. If the new owner(s) does not wish to continue, all 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. *Affidavit Processing Fee $ 5.00 (3) OWNER(S)SIGNATURE Total Due $ 10.00 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. Signnture , / ---''signature botlerj 5 /�Grantor or Grantor s Agent �(t�t.`G�, Grantee or Grantees Agent x.. Name(print) Tana Klebanow Name(print) Richar• S.Kleb: ow Date&city of signing: ,..5—/ r ( ?or+ 1ownS , 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 imprisonment and fine(RCW 9A.20.020(1C)). 755E,. .,-. 12547'1_ s^: t:;2i t::: 1 0 00 c"a USE ONLY COUNTY TREASURER