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HomeMy WebLinkAbout125485 Department of Revenue (lea._ Washington State REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRiNT CHAPTER 82.45 RCW—CHAPTER 458-61A 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. © Name6E,RAt.ts r T-Mtvo t7r'A+-a fetor A 1 NuorrE © Name( ERAL4 E aavo77E Rf74Y4 Muterie 7dcr e$, • Huy&t;.Arn Aa+* tui W e1 ryeCsorma)/PECdr/,yvoT7Eltrh447iNcrba7 //y.1014 • cLO c4 W ti 12 Mailing Address 2o 3 5E4w+44 iaLItce L..Jz Mailing Address .?03 6-EAb✓AAy iL.Ae.E 0 City/State/Zip Pei.T LW:ILeuSi WA 9'8345 m ceCity/State/Zip Pa/LT L vbLeu1,WA 9834.5 Phone No.(including area code) 34o-4"/ 7-09 6.3 Phone No.(including area code) 3/v0-537 Qkv.3 II List all real and personal property tax parcel account Send all property tax correspondence to: Same as Buyer/Grantee _numbers umbers—check box if persso{nal property List assessed value(s) Is Name 15 tU oO 1 . -0. 1 ❑ 31 ) L1OO Mailing Address _ —1 7 City/State/Zip `7 7 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 to each page of the affidavit) , U `� , ``L'' WAt�6AZ-, et Svl`x) nz i�r i rva 1 c_y ►> I N VQLu.► C : . aIC Co�, , in i wit u_6A s (2 5 ib3 �PziA6r-I 165, AeCot' I NG To 1 H f cUAy��1 Ioa� T ie f?i I z.cc OR_0-,A> h1�N`�F-�i jT.FrE,.� ,N; CD (9 ;_\j f Z c Q_l�I N1 (N)Ut IN!V4Z.. 34 iS Z -At3 / Pi MEC iYg., 'S 1 +lk;W6 1n-t Select Land Use Code(s): CI! Selecf Land Use Codes El 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 84.38 ROA)(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? 6 YES NO If claiming an exemption, list WAC number and/-reason for exemption: Is this property designated as forest land per chapter 84,33 RCW? El 0 WAC No. (Section/Subsection) 7 s 'n0/ Az// .2.¢4 Is this property classified as current use(open space,farm and 0 0 Reason for exemption)71,44,60-4/2_%U /( A9LE iI JaAic-j/1eis7 agricultural,or timber)land per chapter 84.34 RCW? Is this property receiving special valuation as historical property ❑ ❑✓ per chapter 84,26 RCW? f f If any answers are yes,complete as instructed below. Type of Document S.)A721 a y to lgiell 1j7 beED (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) /4.... Y', NEW OWNER(S):To continue the current designation as forest land or Date of Document 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 RCVS,-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 0 does not qualify for continuance. *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) 0.00 NEW OWNER(S):To continue special valuation as historic property, Subtotal $ 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 A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX PRINT NAME *SEE INSTRUCTIONS © I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AN---D CORRECT. Signature ofSignature of ) WI [ Grantor or Grantor's Agent � `0 _ Grantee or Grantee's Agent _� C &" Name(print) �jE [.D ler /J/Werra— Name(print) 1.26C6"I i► II)a0 r Date&city of signing:6/2(7/2bi& ilrtT iota 615 aJ Date&city of signing: C7/.2-'•>I, 'i 6, PeCCI. 1C: WS.C7=h,LtiA 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 9,.20.020(I C)). REV 84 0001a(01/04/16) THiS SPACE-TREASURER'S USE ONLY COUNTY TREASURER ?Si) 0 . (10.:,: _