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Revenue REAL ESTATE EXCISE TAX AFFIDAVIT
Washington State CHAPTER 82.45 RCW-CHAPTER 458-61A WAC This form is your receipt
PLEASE TYPE OR PRINT 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.
1 hNt5bCtAnd 2 Maria Escobar-Bordyn, a married person as her
Name James M. Bord n Li ..i , � , yi Name separate property
W o Mailing Address -2.- w Mailing Address 30 Admiralty Lane Unit 322
city/State/Zip h �,� �- City/State/Zip Port Ludlow, WA 98365
5 �"WAS 7
Phone No.(including area code) � Phone No,(including area code) � � trI5
3 Send all property tax correspondence to: List all real and personal property tax parcel
P P Y p l�Same as Buyer/Grantee account numbers-check box if personal properly List assessed value(s)
Name ❑
Mailing Address bl G�` ❑ Z5 L:31 )i
City/State/Zip ���?? ❑
Phone No.(including area code) ❑
4 Street address of property: 30 Admiralty Lane Unit 322, Port Ludlow, WA 98365
The property is located in❑unincorporated County OR within II city of Port Ludlow
❑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)
Apartment No. H, a residential apartment of Admiralty No. 2, according to survey and set of plans
thereof filed under Auditor's File No, 229492, recorded in Volume 1 of Condominium Plans, pages 31
through 39 inclusive;
Together with 4.42 percentage of undivided interest in common and limited common areas and
facilities appurtenant thereto as described in the Declaration of Condominium under the Horizontal
Property Condominium Regimes Act of the State of Washington as recorded on the 28th day of July
1975, under Auditor's File No. 229492, and as amended by Auditor's File No. 235404, both records of
Jefferson County, Washington
5 Select Land Use Code(s): 14 7 List all personal properly(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 ❑ p
chapters 84.36,84.37,or 84.38 RCW(nonprofit organization,senior
citizen,or disabled person,homeowner with limited income)?
6 I YES NO
Is this property designated as forest land per chapter 84.33 RCW? 0 RI If claiming an exemption,list WAC number and reason for exemption:
Is this property classified as current use (open space, farm and ❑ E j
agricultural,or timber)land per chapter 84.34 RCW? WAC No.(Section/Subsection) 458-61A-203 (1)
Is this property receiving special valuation as historical property per ❑ Reason for exemption Establish separate property between
chapter 84.26 RCW?
If any answers are yes,complete as instructed below. husband and wife
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE)
NEW OWNER(S): To continue the current designation as forest land or
classification as current use(open space,farm and agriculture,or timber)land,you Type of Document Quit Claim Deed
must sign on (3) below. The county assessor must then determine if the land Date of Document 05/23/2016
transferred continues to qualify and will indicate by signing below. If the land no
longer qualifies or you do not wish to continue the designation or classification,it will Gross Selling Price $ 0.00
be removed and the compensating or additional taxes will be due and payable by the
seller or transferor at the time of sale. (RCW 84.33.140 or RCW 84.34.108). Prior Personal Property(deduct) $ 0.00
to signing (3) below, you may contact your local county assessor for more
information. Exemption Claimed(deduct) $ 0.00
Taxable Selling Price $ 0.00
Excise Tax: State $
This land 0 does 0 does not qualify for continuance.
Local $
*Delinquent Interest: State $
DEPUTY ASSESSOR DATE
Local $
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY)
NEW OWNER(S): To continue special valuation as historic property, sign (3) Delinquent Penalty $
below. If the new owner(s)does not wish to continue, all additional tax calculated Subtotal $
pursuant to Chapter 84.26 RCW,shall be due and payable by the seller or transferor
at the time of sale. *State Technology Fee $ 5.00
(3)OWNER(S)SIGNATURE
*Affidavit Processing Fee $ 5.00
Total Due $ 10,00
PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
8 I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Signature of �–
Grantor or Grantor's Agent `� l�� U Grantee or Grantee's Agent ).)t /tll2%F-jGi e2. j `�
Name(print) James M. Bordyn Name(print) Maria Escobar-Bordyn
Date&cityof signingJJ
_� .��h/i%�� i�?�lCot ;,r� �} Date&city of signing 5/2,5/ke /7tYjiE`v�.%C�;
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.20.020(1C)).
REV 84 0001a(6/26/14) THIS SPACE-TREASURER'S USE ONLY O County Treasurer
Escrow No.: 0067157-OC-CK ❑County Assessor
0 Dept.of Revenue