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HomeMy WebLinkAbout125482 Department of 6C,?11 Revenue Washington State REAL ESTATE EXCISE TAX AFFIDAVIT • This form is your receipt PLEASE TYPE OR PRiNT CHAPTER 82.45 RCW—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. © Name c C(ZAt D r r(•(/o T7 #1 -+) 19044t 1Nvo7rE ® Name6(44L0 K Nvo77Eikii--ay4 firverre 7hd4fgEs, . x //u5 g•A.rre At-to to ire' mor 1II)EtsE�QAL.,D/P90/NuDr lI1/i4(�TRvaIti7 f/fJo1/, c4 Mailing Address 20 3 5644..u4604 10110.6-a z z Mailing Address 2 03 nit-Aunty p ...isce L7.1 a 0 City/State/Zip PaR7 1..uOLouNi WA 98345 m ce City/State/Zip Po x7* I.ubL i ,4A 9a3ia cD Phone No.(including area code) 34o-'Y?7-0863 Phone No.(including area code) 3/v0-4137-Oka List all real and personal property tax parcel account III Send all property tax correspondence to:OSame as Buyer/Grantee numbers-check box if perso al property List assessed value(s) Name1:1�f Mailing Address -1 56 5 )0 ii d*I1-7 fl City/State/Zip 7 Phone No.(including area code). n IIStreet 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) w i ���� V`1\) C 1 k--- ''K '' f"l oGf't3c. j �v'o 111 tIQ i LL PA A CDN$Jt':Aki N t u.n�. i`..) ilv 1'Y>•t. 2, Cf- 0,0u m tk) i VLYY.:; P -c_s l C3 iii r‘ (.a to Ti OS , f oc c i i`�; To TO,' Ia-:C.l,A�ATit�t� H , cct-co 5 LW o �� 3EFF cc 0 N) c r,-�N i y 0 (T TZ'S FILE : . 43 T7 #�t� 3iT(.A.ATE Z N TI-1, Co u- b y Cf . -fe 6t; i 5-5)-TE: a kA51-11i, iL 111, Select Land Use Code(s): _ Select Land Use Codes III List all personal property(tangible and intangible)included in selling price. enter any additional codes: (See back of last page for instructions) YES NO Was the seller receiving a property tax exemption or deferral under 0 0 chapters 84.36,84,37,or 8438 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? © If claiming an exemption, list WAC number and reason for exemption: YES NO / Is this property designated as forest land per chapter 81,33 RCW? 0 0 WAC No. (Section/Subsection) 7 L,SS — ; A-2 X1(.2.$-) Is this property classified as current use(open space,farm and 0 0 Reason for exemption1 s ivf/5t T ,&VOCABEC I/VI AIG 0-1157 agricultural,or timber)land per chapter 84.34 RCW? Is this property receiving special valuation as historical property 0 0 per chapter 81.2612C11? If any answers are yes,complete as instructed below. Type of Document 57-Aroma`' (N ARRA AITY 1)E -5 ) (1)NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) Document ir. NEW OWNER(S):To continue the current designation as forest land or Date of � ( � I 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 transfen•ed 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 84.33.14(1 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 I Local $ 0.00 This land 0 does 0 does not qualify for continuance. *DL elinquent 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 12.CW,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 flI CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of / Signature of �,� �x - �, , 41/.n Grantor or Grantor's Agent; .J1 F _ Grantee or Grantee's( Agent_ �V r I I f - Name(print) GE�L,b l� l/,,va77� Name(print) 1 € ' i t1 `11H Huy I�'d Date&city of signing: 9/201/, YbrtT 1 wo rlS a)`Iv♦h Date&city of signing: 512-10 /Mr t Pocci i C'.1k)t,)sc 7',.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(I C)). REV 84 0001a(01/04/16) THiS SPACE-TREASURER'S USE ONLY COUNTY TREASURER 755864 12.5402 I:5/262'2016 10 00* 12 cLtIS2D