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Home My WebLink About125495 reDepartment of � )'"' ‘(,:1(. 0 756 evenue AlshmtonSuft REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt 01 S Li PLEASE TYPE OR PRINT when stamped by cashier. t 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.82296JMM 0 Check box if partial sale of property If multiple owners,list percentage of ownership next to name t. Name Daniel A.Fischer and Virginia Fischer,husband Name Jesse Vandeneeden,an unmarried individual and wife w O Mailing Address 491 N Jorsted Creek Rd ce H Mailing Address 10620 5 5TH AVENUE S z S1 City/State/Zip Lilliwaup,WA 98555 m City/State/Zip Seattle,WA- __ �� " t7 Phone No.(including area code) (360)731-4200 Phone No.(including area code) (206)605-8700 3. 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 Jesse Vandeneeden 713 021 010/18959 ❑ 38,960.00 Mailing Address 55 Ave S TAX q ❑ City/State/Zip Seattle,WA 98007 0 Phone No.(including area code) (206)605-8700 0 f'VI al) gliStreet address of property: XXX Dowans Creek Rd,Forks,WA 98331 This Property is located inunincorporated Jefferson County OR within❑city of Forks 0 Check box if any of the isparcels 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) SEE EXHIBIT"A"ATTACHED HERETO AND MADE A PART HEREOF FOR COMPLETE LEGAL DESCRIPTION ® Select Land Use Code(s): 91 7. 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, ❑ X homeowners with limited income)? ® 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 ❑ x agricultural,or timber)land per chapter 84.34? 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. Type of Document Statutory Warranty 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 25,2016 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 $ 115,000.00 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 be 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 $ 115,000.00 Excise Tax: State $ 1,472.00 This land ❑does El does not qualify for continuance Local $ 575.00 *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $ 2,047.00 NEW OWNER(S): To continue special valuation as historic property, 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 $ 2,052.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX I *SEE INSTRUCTIONS ® I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT Signature of ,, - D Signature of di---a ,......,Grantor or Grantor's Agent ! /�%,4:1G�t Grantee or Grantee' , � � Name(print) Daniel A.Fis her Name(print) Jesse 'anden eden- Date&city of signing: f ///" y r Date&city of signing Perjury: Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a maximum term of not m re 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(04/30/09) THIS SPACE—TREASURER'S USE ONLY COUNTY TREASURER i K • EXHIBIT A That portion of the East 117.83 feet of Government Lot 10, Section 2, Township 27 North, Range 13 West, W.M., Jefferson County, Washington, lying Southerly of the Bogachiel River; EXCEPT County Road. ALSO,that portion of Government Lot 9, Sections 2, Township 27 North, Range 13 West, W.M.,Jefferson County, Washington, lying Southerly of the Bogachiel River; EXCEPT County Road; Situate in the County of Jefferson, State of Washington.