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HomeMy WebLinkAbout125480 Department of rat, Revenue Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRiNT CHAPTER 82.45 12CW—CHAPTER 458-61 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. MI Name gERAt.O.r Tf do Tr•A.Jt. feezy A 1 NVoT?E ® Name eat - / mo/E ' ' Tau• it J f, x /j/uS 4444,ro Aa+a CuieEw ef rig" srin 1 Pam- mom-lerh4Critvobsir M014, ao c4 t1J ti a Z Mailing Address 20 3 5Egw i Aimee Z Mailing Address 2 0 3 S'es:qunky p'L,,q N 0 City/State/Zip P6/.T 1.vtoLeIA WA 9836 �2-.1a4 City/State/Zip pd 11.7 I.vo1drJ,�A 983te5 Phone No.(including area code) 31.o—17 7-0963 Phone No.(including area code) 3470-4/37—Og(o3 List all real and personal property,tax parcel account © Send all property tax correspondence to: Same as Buyer/Grantee List assessed value(s) (numberss--check box if per, nal property /� Name 5(03 ? io�) �ci t )� isic o Mailing Address rl City/State/Zip El 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 t each page of the affidavit) UNC Ac fi'vb. AG a '' 1\161. C'CQ rA)WIUA 111 xl0; 0 ( Do nil INi(I ( - ?Zbetti uj t wt.,, .f c f.- C. -,W1 tt.c:+ 111 IN 1 tA.11\S . V REL rl 1 t-H P•z H --03 A CCd l b- i AC. 1 i a,� r o s.; c HC E- , (I-L—C3 ri, ALU V(�f–.a7 JE-S.fc?sc�Ki cc)t .v ,/ P -eOz To.o �_.F� - t3 to 14_7 ),� )\) ei m. ;a,)G5 4-::.1)t .5 i H EC: E:.--1.6 �,i..1,.M NUL i N c Ii_:,A`►c IN IhE COO►Ji Of FfG oe,1 STriri OF lt. 114,( 00 illifSelect Land Use Code(s): 111 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 RC W(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? 6If claiming an exemption, list WAC number and reason for exemption: YES NO is this property designated as forest land per chapter&1.3312C'W? 0 0WAC No. (Section/Subsection) 't/SS • f A 2 i/ 21,-) Is this property classified as current use(open space,farm and ❑ ❑✓ Reason for exemption 72eA6ST) % AszoGH3 Le- Zi 6)./4-17-41-57 agricultural,or timber)land per chapter 84.34 RCW? Is this property receiving special valuation as historical property 0 0 per chapter 84.26 RCW? ,1 If any answers are yes,complete as instructed below. Type of'Document S!/ MT6.12lW Y ARRA PITY I)E6tD (1)NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) I NEW OWNER(S):To continue the current designation as forest land or Date of Document 3( 1x.1 jiY' 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 RCW 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 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 flI CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of' Signature of Grantor or Grantor's Agent � /� _ Grantee or Grantee's Agent...' �rUU�� Name(print) F , E �jE4C4L,D /j iu8T7" Name(print) 1 EcL`'i 'I rj►QC' (77-€ Date&city of signing:Z/29/204, Poitt/owFlStr'bJ Date&city of signing: f ') i C I I'`,:ti�v�f ,�?'1 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(12CW 9A.20.020(IC)). REV 84 0001a(01/04/16) THiS SPACE-TREASURER'S USE ONLY COUNTY TREASURER k K--,. 1.75 : 25430 ,tom_ iii 00 .