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HomeMy WebLinkAbout125478 Department of rt?1.Revenue Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRiNT CHAPTER 82.45 R.C'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. Ell Name geRARP F T—ftLo rTtAAJb "ctn. A INvo7?E ® Name 44 . /WGPO, j , ' THvo it J ,41,.. ed /1/u 6 6A.uo A...+a LQ1 w Tl e ERM,b;P Csy/livor> '1Iwri47Rv4Ttnte-.0"lo14 a o //►� z Mailing Address 2o3 5Eq js lv/.Aee z Mailing Address _2O3 SEA&,✓•Ay (PLAce City/State/Zip PdILT Lu3La iA WA 9B3t5 m ce City/State/Zip Pa Ai' I.v1,16..1/41A 993L.S Phone No.(including area code) 34o-137-0863 Phone No.(including area code) Aso-4137-O L 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 per nal property p Name 51,3 00 70 3� tIC135 ❑ 351 c/10 Mailing Address n City/State/Zip n Phone No.(including area code). n 111 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) A i-i/064eL0 e-$-r/►7E IN UN/7 441'6.3" 517E ''G 4 MANGKL CON Doh,1 N/UM 11'1 J c /A, 4 CON DO.44toti N4 4EGen4'60 /N VotuMs 442 of CO WO OA./NAMP , Akr89 iwRovGl4 751- AGCoJt+obac 707/ DeoLAturried7iicvcco6 REOoR,AC--1, VNO JEfre42tea1 CO 101471. 4tGoIu 1HC Nu4,16.-51. Vo5-qeo I *,b Awl 6 mcwoMewrS // .e4E70 . 1111! Select Land Use Code(s): Ell 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 RCV+'(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? © If claiming an exemption, list WAC number and reason for exemption: YES NO , i is this property designated as forest land per chapter 84.33 RCW? ❑✓ L❑ 7 WAC No. (Section/Subsection) SS - A ,A-211 .2 g+) Is this property classified as current use(open space,faim and ❑ ❑ Reason for exemption7Ir?.A;\J5gi2 T I V0�� L Iv4C`i vS7 agricultural,or timber)land per chapter 84.34 RCW? Is this property receiving special valuation as historical property 0 ❑✓ per chapter 84,26 ItCW? If any answers are yes,complete as instructed below. Type of'Document 5/ArefTbn y IA/ARRAN/7Y iE1=4) (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) • NEW OWNER(S):To continue the current designation as forest land or Date of Document '..72 ((rj I i tp 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 $4.:;3.140 or RC:'\'+-84.34.1118).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 ❑does 0 does not qualify for continuance. *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) 0.00 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 *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 $ 10.00 A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX PRINT NAME *SEE INSTRUCTIONS 1111 I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING iS TRUE AND CORRECT. Signature of , Signature of ........L.A., Grantor or Grantor's A en — Grantee or Grantee's Agent_ G `-C_.. 1 Name(print) GE,(AL,D f lt/� ( a7TE Name(print) 1 6CC`'i t1 114 a 67 LITE- Date&city of signing:�9/20/L PtttT/nuAS a)Vlts Date&city of signing: 5/,.2.. bk)i G Pay; 1 C SuSc t' .t\, a 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(I C)). REV 84 000la(01/04/16) THiS SPACE-TREASURER'S USE ONLY COUNTY TREASURER _,n-, .-.._ ,