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HomeMy WebLinkAbout125477 Department of Revenue riga Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRiNT CHAPTER 82.45 ROW W-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. 0 Name.6_42A,Liz.r Tttu.rrEA,Lito fetLir A !Nuorre U Name6E4ALO F %NvorrE PIGGY'!THvcri /Md4rEESr cL o /I/u 5 6Auo At-so CurFE w Cr McCelAL.DI PD.Ari u077eII1/r(7RvsT4,A7 (172014 a4 14 a az Mailing Address Zo 3 SEgw �f �n. s Z Mailing Address �O sem uAY GLA ee v City/State/Zip PaILT ,Lul Le6.11 W A 9a-us m City/State/Zip Pe AT i vbL su31VA 983`S Phone No.(including area code) .3is0-.1?7-08 63 Phone No.(including area code) 3w0-x/37-©27n('3 . © 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 pers at propertyro�' II p Name 9.54.301 '2 d7 Q va5-5-❑ 3t,I (..O Mailing Address n City/State/Zip n Phone No.(including area code) n flStreet 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) n� 0Nrrt-7 ` L' 1/AtJGnte A Co AA:,eM,"J1v,M Ree-oito� Ay Vo2u-44e Z dF C,o.VaofkAi40Ety..f PAG C5 /03 i,i'4a 4 los, A .CO,U 0 7XC DEUAi97?o4 2 E'of, geCo.Q000. Uivir jer .YLSwv Gdur.tTY RE CoA-.O,1.74 Nu"'1Scte 4234"5 4,-Q Airy A41cwn_AI zo.rrs 7-d E70. EliSelect Land Use Code(s): III 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 0 0 chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? 6 YES NO If claiming an exemption, list WAC number andreasonfor exemption: is this property designated as forest land per chapter 8<4.33 KW? 0 0WAC No. (Section/Subsection) q5 - A-2/1 .2.a} Is this property classified as current use(open space,farm and 0 0 Reason for exemptionnN(-g\j-err A-c, Vy Yo C c ble.. agricultural,or timber)land per chapter 84.34 RCW? Is this property receiving special valuation as historical property 0 ❑✓ t.V '^c.)-- 'r S\-- per chapter 84.26 RCW? ,f If any answers are yes,complete as instructed below. Type of Document �I rATL,T&R (A y A NTY 166I (1) NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) NEW OWNER(S):To continue the current designation as forest land or Date of Document 3((t classification as current use(open space,farm and agriculture,or timber)land, Gross Selling Price $ 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.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 RC' 84.34.108).Prior to signing(3)below,you may contact Excise Tax : State $ 0.00 your local county assessor for more information. 0.0050 Local $ 0.00 This land 0 does ❑does not qualify for continuance. *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $ 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 *State Technology Fee $ 5.00 additional tax calculated pursuant to chapter 84.26 R \ ,shall be due and payable by the seller or transferor at the time of sale. *Affidavit Processing Fee $ (3) OWNER(S)SIGNATURE Total Due $ 10.00 A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX PRINT NAME *SEE INSTRUCTIONS UI CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING iS TRUE AND CORRECT. Signature of � Signature of Grantor or Grantor's Agent Ls'Grf.►G — Grantee or Grantee's( Agent �r�_�'�e%,aw } va7?� Name(print) 1 eG6'1 ?'I Q i 0 (If Name(print) GEiL//L,D � /// Date&city of signing:�h9/2Oib, ALT 1 a a5tr-4b) Date&city of signing: 51,2-‘:, (, i)t L Pao low;vsC ..;('i 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(RCW 9A.20.020(l C)). REV 84 000la(01/04/16) THiS SPACE-TREASURER'S USE ONLY COUNTY TREASURER