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HomeMy WebLinkAbout125484 Department of Revenue re4 Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRiNT CHAPTER 82.45 RCW-CHAPTER 458-6 1 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) ❑ Check box if partial sale of property if multiple owners,list percentage of ownership next to name. El Name cGRgt.o. F r ituorrEA.-kb 1ki r A I NVa7?e © Name6E/taLo F. o7TE l)eUYIF THvdTTE MtlifireS/ x /j/u 5 6Aa,ro Ar-+a Wird- W or me-I6�AI.A/PEx6y)vol/ ?s i�i447Rvsl�A7 //p2oi. aG O rz4W az Mailing Address 203 SdAuJ Itht-e Z Mailing Address 209 5-0/Al , "i..AeE City/State/Zip PeRT JvDLouSt W \ 941'31.5 �w ae City/State/Zip paA T kubi0.01A 983 5 Phone No.(including area code) 34a-137-OS 1.3 Phone No.(including area code) 34,o-2137-t7 3 © Send all property tax correspondence to:Ename as Buyer/Grantee List all real and personal property tax parcel account List assessed value(s) numbers-check box if personal property Name , o9P//07 / IL 0 � Mailing Address CM 41 n City/State/Zip n Phone No.(including area code) in IIIStreet 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) 2. °F f1NJ'f K 7 'K' Nf>,NGAA eau Ooi+f/N/uAt.i ACothdO& jIoM fRFJro� Go ,,„,/ VOLvme MC ,Da.c.�r1 71 o.�7 71j o1 GO.u00M/N1v�M tel/ Qi4Ge If 1...i 404)6W //fes AGGoM.�nr4 7Z) f AdGod-DC- vrva.-.rL- Jager-l2-sc.J 40,,,ery AL,DIIon5 Fc.< NO.4F7700 Ataal, AtuY A M E-.voM 6A,'r5 %!'GA-S-70, Sr74.r.►-r€' /d( ire Co...N7Y of JefFFnSoN.1 Srerrr of- (045)4(NGTO J 1131 Select Land Use Code(s): 5 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 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? 6YES NO If claiming an exemption, list WAC number and reason for exemption: / ` is this property designated as forest land per chapter 8.1.33 RCW? 0 0 WAC No. (Section/Subsection) L 7 SS 'Lai A 2// 214 1) Is this property classified as current use(open space,farm and 0 0 Reason for exemption 7 ,vfttSQ %p Revo�`A4 , bvik6'70047 agricultural,or timber)land per chapter 84.34 RC W? Is this property receiving special valuation as historical property 0 0 per chapter 84.26 RC\V? ,' If any answers are yes,complete as instructed below. Type of Document �i/4T/JToR' pW ASA NT( 66 .-I2' (1)NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) t ` l_ NEW OWNER(S):To continue the current designation as forest land or Date of Document i I , i • -r- D/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 84.33.1 40 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 ❑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 RC W,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 Grantor or Grantor's Agent l.Z _-� — Grantee or Grantee's Agent •_C. �,� (i__l ,Cq. � Name(print) 6.-E,(41...1) r `//vo?T� Name(print) 1 ESC`'i r-i 71 RV(Ff Date&city of signing929/2O/L Atf.7 Je !~15 b)Wei Date&city of signing: 5/2-w 1, 4)16, PC C I C :VSE 70N,L'A Perjury:Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a maximum tern 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(l C)). REV 84 0001a(01/04/16) THiS SPACE-TREASURER'S USE ONLY COUNTY TREASURER i)q 55866 1.254 *5/26/201 6 l 0 .3C. i (Ci;Lt /.°