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REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt f� 0
PLEASE TYPE OR PRINT when stamped by cashier.
CHAPTER 82.45 RCW—CHAPTER 458-61A WAC
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED
(See back of last page for instructions)
File No.82235JMM
❑Check box if partial sale of property If multiple owners,list percentage of ownership next to name
Name Norma Fried,as Successor Trustee of the Lyle Name Johnson Family Properties NW,Inc.,a Washington
G.Fink and Pearl L.Fink Revocable Living Trust corporation
dated June 23, 1993
7f Mailing Address 1009 22nd St. ee w Mailing Address 211 Grow Ave.NW
- z
City/State/Zip Port Townsend,WA 98368 City/State/Zip Bainbridge Island,WA 98110
Phone No.(including area code) (360)385-9309 Phone No.(including area code)
Send all property tax correspondence to:❑Same as Buyer/Grantee List all real and personal tax parcel account
numbers—check box if personal property Listed assessed value(s)
Name Johnson Family Property NW Inc . _' 948 308 804/27632 ❑ 25,200.00
Mailing Address stir `<'j ❑
City/State/Zip . e , . ; : y0 R•,r.,�.,�..:.. P / _ :0.41'.41� 4J,- qf�` "L3 ❑
Phone No.(including area code), 'erg,—&l ..,2/.fc:�37 ❑
Street address of property: XXX 21st St,Port Townsend,WA 98368
This Property is located in 0 unincorporated Jefferson County OR within ycity of Port Townsend
0 Check box if any of the listed parcels are being segregated from a larger parcel,are part of 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)
Lots 7 and 8, Block 88 of Eisenbeis Addition to the City of Port Townsend, as per plat recorded in Volume 2 of Plats,
page 24, records of Jefferson County, Washington.
Situate in the County of Jefferson, State of Washington.
® Select Land Use Code(s): 91 ® List all personal property(tangible and intangible)included in selling
price.
Enter any additional codes:
(See back of last page for instructions)
Was the seller receiving a property tax exemption or YES NO
deferral under chapters 84.36,84.37 or 84.38 RCW
(nonprofit organization,senior citizen,or disabled person,
homeowner with limited income)?
0 x
® YES NO
Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption:
RCW? ❑ x
Is this property classified as current use(open space,farm and
agricultural,or timber)land per chapter 84.34? ❑ x WAC No.(Section/Subsection)
Is this property receiving special valuation as historical
property per chapter 84.26 RCW? ❑ x
Reason for exemption ----- ,
If any answers are yes,complete as instructed below. , I U�
Type of Document ... xstee;s Deed
(1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE)
NEW OWNER(S): To continue the current designation as forest land or Date of Document May ,2016
classification as current use (open space, farm and agriculture, or timber)
land,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, Gross Selling Price $ 98,000.00
If the land no longer qualifies or you do not wish to continue the designation *personal Property(deduct) $
or classification, it will be removed and the compensating or additional taxes
will he due and payable by the seller or transferor at the time of sale. (RCW Exemption Claimed(deduct) $ No
84.33.140 or RCW 84.34.108). Prior to signing(3)below, you may contact
your local county assessor for more information. Taxable Selling Price $ 98,000.00
This land Excise Tax: State $ 1 254.40
❑does ❑does not qualify for continuance
Local $ 490.00
*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 $ 1,744.40
sign(3)below. If the new owner(s)do 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 $ 1,749.40
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 RRECT
Signature of /� Signature of
Grantor or Grantor's Agent " fi��_ 4y _7`/ C� Grantee or Grantee's Aleut
Lyle G.Fink and Pearl L.Fink Revocable Living
Name(print) Trust dated June 23, 1993 Name(print) Johnson Fa .i Pr I.; t NW Inc
Date Si,:city of signing: j/&ep/ka p Date&city of signing 7frIgnifalliffiffirs
Pcr,jur}: P:111 till 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
""' `'both imprisonment and fine(RCW 9A.20.020(1C).
'S USE ONLY COUNTY TREASURER 0
.755905 1254'5'3 :4:r2601_ 1,749,40*74 ,40*
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