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HomeMy WebLinkAbout125487 Department of Revenue ts":4 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. fl Name GeaA»> T P r Tit rre-A44, PAW" A /1'1Vo7?E © Name664ALO F. //11,077E '&SLYn Thvierre 7Jff r x #0613AAro A...0 Wire' w ef ruff[~Eilifu 11) .6yjroTirlorrrig71R1•srtscrEa3fr 016 a Mailing Address 2o 3 JEgwdoi tOLn-� i Z Mailing Address 2o 7 5 cit ,✓ y tPLAce d g City/State/Zip P4RT Lv Leusi WA 98365 i City/State/Zip Pe aT (vDLeuJLNliA 983Ls Phone No.(including area code) 34o-lig 7—OS b3 Phone No.(including area code) 3410-1137—Oka ® Send all roe tax correspondence to: List all real and personal property tax parcel account property rty p (/Same as Buyer/Grantee List assessed value(s) nnumbers—,check box if rs(o�nal property ^� T Name ,.41300/0•7/A 0J L3 ❑ d) 130 Mailing Address 7 City/State/Zip n Phone No.(including area code) 0 aStreet 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) UNI/5 74 A,►p 6 A/ A' b-IANC144- COtrOO M/N/L H"r ...Mtn;A Co.4bop,huhr.A. .R6GollAs2, /Ai Vo LUM4 A/o. 2, or GoA+daM.Nhf.A.AS, A6ES 75 Mao ea 04`119 4 AcGoM'ri 70 Wie t) LAitAT.•v TNn. ( Fo 1 ACdit , ufomt, 45rtrc .S.AI Co cua7Y RscoA+rrrAJU,m&r✓L 39rd 9o) Aw.r Anti A M ap.omes,fters '7K'vt 7o. ll 5‘17'‘)A-re Au rye CO uw.7 ti of Jevc 5747e. 1J$S OF H/M67oN Select Land Use Code(s):11111 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 ❑ p chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior citizen,or disabled person,homeowner with limited income)? © 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? 0 0 WAC No. (Section/Subsection) x/59 —4,J A-2Ii( 2 Is this property classified as current use(open space,farm and 0 Reason for exemption ` `-144>S7r agricultural,or timber)land per chapter 84.34 RCW? piQAySFesJ % AV OG Ria LE Itv.r11G Is this property receiving special valuation as historical property 0 ❑✓ per chapter 84.26 RCW? I.' If any answers are yes,complete as instructed below. Type of Document S%4TLl. &12.11 (/V A gaZiel f/TY t)EE C) (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) /q(t /_ NEW OWNER(S):To continue the current designation as forest land or Date of Document 31 1�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 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 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) Subtotal $ 0.00 NEW OWNER(S):To continue special valuation as historic property, 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 ROW,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 Signature of ��lJ_ ( - � � Grantor orr �y¢.tGrantor's Agenk ,r,LR, ✓ _ Grantee or Grantee's Agent Name(print) 6E,(/JL,,p Jr:..- qL d ` r7E Name(print) 12E66 r'1 0'FIE Date&city of signing�9/204p AkT/D..II.15 a) Date&city of signing: 5/2- bii:ii(o Pati ii fGW kkisE i",L.{A 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(ROW 9A.20.020(IC)). REV 84 0001a(01/04/16) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASU(R)ER ,'55069 12 ._ :1:5 S26/2014 I C .001: 1 IZ