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HomeMy WebLinkAbout125486 Department of \`�,,. 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. III Name gFl2A1 t. r. Titu0 rTEA+JI, ferG.6,7 A INvo7?E ® Name ail . ' Thi it J r ce /I/v 5 AA.uo Awa 1,.,iFE w of T �s ZALA;Pat, -111itr47frv47 brt �r72o14 Ix c4 w w Mailing Address 20 3 5 UJ$+Y ! V z Mailing Address .?03 S'6flw�,y� /PL-Ace w t7 City/State/Zip PdRT Lvt►LerrSi \AIA 94330 m ce City/State/Zip paIQ.T Lvei0.01 A 9834.5 Phone No.(including area code) 34a-'Y37-091.3 Phone No.(including area code) 3/00-L/37-O 43 © Send all roe tax correspondence to: List all real and personal property tax parcel account property rty p Same as Buyer/Grantee numbers-check box if personal property List assessed value(s) Name 93?03oa I&i / q"/ 0 Mailing Address n City/State/Zip El Phone No.(including area code) 0 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) , UNIT A4 HANGAA. GoADoMJN/✓M A7 JC/4/ A CouDoMIbi/UM gec0,4,060 "4 Yotw►+G No.. 2. or Goev pon#Nwm S, PA6et 73 7rltoodo 7B,"AGGeI 6 7; Tat DECLA4'7,o*1 /1/c�Fol Ra toitotsr► Ulu, ,/EFF ?5C J Co.,ter V 46CoR.oiNG /Vuu9 a 3&8 'fol A.110 Arnstj A itiGiv ,n/4+ t 7% 717 . 5-171.476.476 t N -fle t v.,try of 36frecn.s.a Sr.>C of teifisN,N 6-7-00,1 Select Land Use Code(s):III! 1111 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)? 6 YES NO If claiming an exemption, list WAC number and reason for exemption: L/ l A Is this property designated as forest land per chapter 84.33 RCW? 0 0 WAC No. (Section/Subsection) 7SS `L.I '�211(2_. , )' Is this property classified as current use(open space,farm and 0 0 agricultural,or timber)land per chapter 84.34 RCW? Reason for exemption 72fAis ro eVQCAR LE .1.LVivL fii57 Is this property receiving special valuation as historical property 0 0 per chapter 84.26 RCW? If any answers are yes,complete as instructed below. Type 5,A A W7Y 66E-4> T e of Document TtJ,Thr y (A (1)NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) 5/ / ad s 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 RC1'84.34.108).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 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 © I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. i Signature of �/� Signature of g > G — Grantee's0,, LLQ �ttO - Grantor or Grantor s A en Grantee or Agent_ (` /� Name(print) GE,eAG� l� /ht nVa77� Name(print) P€66-1 Y1 TI•-)uc' !Ff ��} Date&city of signing:�9/2WJ/� ]7sit.T/NIS DJ Date&city of signing: 5/,_ria'I') 1 t Pao 1 l c 4uSf t '' 1,('(T-'� 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(RCW 9A.20.02.0(1 C)). REV 84 0001a(01/04/16) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER TREASSURERRk 75586;.T: 1��}Lr :+:`/26:12016 0..00:t int-me ;'