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HomeMy WebLinkAbout125481 Department ofra Revenue • Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt ' PLEASE TYPE OR PRiNT CHAPTER$2A5 R.CW-CHAPTER 458-61A WAG when stamped by cashier. THIS AFFIDAVIT WiLL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED (See back of last page for instructions) 0 Check box if partial sale of property if multiple owners,list percentage of ownership next to name. 1111 Name 6 2At.. r Tttvo rTEA+-+a feat A INoo7r$ © Name .44 . //Moo tE a , ' MI", l!J x g u 5 134-Aro At-+o tv#FC /� r,_, rf The CCIALI,i PaAr%SI uontr l t rrrt4?ava-tscr //�1 o 1 t, w z Mailing Address 2o 3 SEAW+11`l 10i.A.e >w F- Mailing Address .2o'3 Se itu.t PL.Ac a w vef l-e WA 943345 m ae City/State/Zip pd p..7 L volaw]I\A 983L,S City/State/Zip PLAT 1 r.SI cD Phone No.(including area code) 34e-'137-08103 Phone No.(including area code) 34.o-'137-DS63 List all real and personal property tax parcel account List assessed value(s) © Send all property tax correspondence to: Same as Buyer/Grantee numbers-check box if personal property Name 0:0" / ElMailing Address C16 to 06 700 n 01, 530 City/State/Zip n Phone No.(including area code) n UStreet 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) t iv: 3+ (,V� 5lTEE a G `' HPt ` ^t3r (D1J be N1 IN iLkil -- Fl i 3QI19 P Jd Utv^r G(01�� Vb L {; 0 F C:,v1 J t``>0 ill�V '1 U, Mme. . `Q"' C'a i+1RoiL64-1 9Q,f �t - _'= v V�b �Tt-C --C (I7 ' i L;a; I..0.t v..1._O , 1.L.Gv i L ut).)• ,e Q---J-'•FFEr4 vA v P4C `a� rcJ c . � �\) i.) Iyf' L(-c�5 q 80 ' �'> Y I it -N b AE t i HEti 16 , CG�usYr 511Lvf lc. off) iH€ Coi.kr)T\j OF . ffEie .) , 5iAiE. Of aASH i*6 TO gliSelect Land Use Code(s): IIII List 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 8438 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? If claiming an exemption, list WAC number and reason for exemption: 6 YES NO t� 1 is this property designated as forest land per chapter 84.33 RCW? 0 0 WAC No. (Section/Subsection) 4/Sg `n� A j -'2ilC2-� Is this property classified as current use(open space,fhrm and 0 ❑ Reason for exemption'72t.v5i EVd CAgu 041i/04k- 70 057 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? ',w l If any answers are yes,complete as instructed below. Type of Document 5,,A72s7 fl`f AgRANfry b 'E D (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) Date of Document �(t I Y' NEW OWNER(S):To continue the cumin designation as forest land or 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 Taxable Selling Price $ 0.00 be due and payable by the seller or transferor at the time of sale.(RCW Taxable 84.33.140 or RCW 84,34.108).Prior to signing(3)below,you may contact Excise Tax : State $ your local county assessor for more information. 0.0050 l Local $ 0.00 This land 0 does 0 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, 5.00 sign(3)below.If the new owner(s)does not wish to continue,all *State Technology Fee $ additional tax calculated pursuant to chapter 84.26 RCW,shall be due and *Affidavit Processing Fee $ payable by the seller or transferor at the time of sale. (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 7J Grantor or Grantor's Agent — Grantee or Gra(nt?ee's Agent Ili Name(print) 6jEL4L,D K `/y/Vd77 • Name(print) 1 ESL r1 Out" If Date&city of signings V204. Pot /cur FiS7 aj Date&city of signing: 1/2 1, )'i:t Pccci IC='"k?,)scNN,L' Perjury:Perjury is a class C.felony which is punishable m byimprisonment in the state correctional institution for a maximum term of not more than five years,or by p 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;1.20.020(10). REV 84 0001a(01/04/16) THiS SPACE-TREASURER'S USE ONLY COUNTY TREASURER _... ,:.' 12',;4;::i _ 0 iUu 1 7I5�W1 kJ