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HomeMy WebLinkAbout125479 DDepartment of ti Revenue Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRiNT CHAPTER 52.45 RCW-CHAPTER 458-C i A 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. III Name 6 Qi r rifto rTCA0-cr, jk'Ot A 1 Nv0776 ® Name 6Eaaa4 K //it/077E rrri Y4 filtocare 7JSfeeer o yv s 6A-are Ae-io Lvil leer w ef rig- Er2At At PEx�yT writ-itriptirt+4T el ,f2o14 c4 w aZ Mailing Address 203 SEqujat'i IDin.e" Z Mailing Address 2 07 nicii only PL.Ag..E w N 0 City/State/Zip PdILT LvO Lein WA 948.345- aw g City/State/Zip Pa/i7 L ub1a.,JL\EIA 98345 • Phone No.(including area code) 34o-'137-091.3 Phone No.(including area code) 3470-5/37-001.3 © Send all property tax comes correspondence to: List all real and personal property tax parcel account p Same as Buyer/Grantee List assessed value(s) numbers-check box if perso al property Name 95tv3obiQ0- Q9'I -❑ 3I1a&5 Mailing Address n City/State/Zip El Phone No.(including area code) n ciStreet address of property: This property is located in Jefferson County 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) U'3J i T ') + v A ' HA me, Ak C(.!)3 bo A.I 1.:)1t3-1Y._ A1 ri A Cx IV ba MI i U Yv ' CU 2-E1 1vi \JbLC&,mE NO . a. vV• CO bo 4\0%) IU-MJ P=AGvE --(5,-+ Ttic cOuUi-1 78 i�CC:c?I' INk, 'Tr3 THE tJc.CLA RA-1-.10,,, 1 HE O , /,�Ee6R4 i W) i iZ :1-LFfE�tsi* �it'WT'/ 1.-?,E.. .61-(0inlay„ 41 t.�-Ms`2 •3f 9�f r j PGS; b Any i't Lt-ix) iY‘a,/ t S Tt')C.t&E I T+ _,i� u ir. -1 I f4C Couche y OP aFFC 'rJ ; SIOrC-- CSF (A)65-)itv ) + ® Select 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 chapters 8436,84.,?.or 84.38 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? © If claiming an exemption, list WAC number and reason for exemption: YES NO Is this property designated as forest land per chapter 8,1.33 RCW? 0 0WAC No. (Section/Subsection) 7C� SS -"L.j A 2i/(Z ) Is this property classified as current use(open spacefarm and 0 EDReas on for exemption %71Aa,SFecc s'e /0 YOc* .c ,�1V)wl6 M/S-7agricultural,or timber)land per chapter 84.34 RCW? Is this property receiving special valuation as historical property 0 0 per chapter 84,2.6 RCW? STA If any answers are yes,complete as instructed below. Type of Document S J Are'Te.f Y W ARRA NT`T 66- -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 3(' j (p 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.(RC1V Taxable Selling Price $ 0.00 84.33.1 40 or REAV 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 ❑does 0 does not qualify for continuance. *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) NEW OWNER(S):To continue special valuation as historic property, Subtotal $ 0.00 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 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. Signature of / Signature of (�/�� //��.�� n ,' Grantor or Grantor's Agent 4:1.1,42 I`?,,� _ Grantee or Grantee's Agent .X_3 •. " a ,1 01""� 1 Name(print) .6169G,D l� ua7T� C ('� II `J>l Name(print) 1 E `1 ?1 ��'�uG+ d I-€ (} Date&city of signing: 99/204, IItt7/or )454-dbJ V,tv Date&city of signing: 5/;21../, 4')I L Pa a c.i,o kvS.0 tM\ �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 9.-x.2.0.020(I C)). REV 84 0001a(01/04/16) THiS SPACE-TREASURER'S USE ONLY COUNTY TREASURER xci 75,„,,6 c.3 125479 15 t1 125t,f t tel,