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Submit in County Treasurer
perty is located.the REAL ESTATE EXCISE TAX This for is your receipt when stamped
county in which property is located. by cash-r. Pay by cash or certified
• CHAPTER 82.45 RCW check to ounty Treasurer.
PLEASE TYPE OR PRINT CHAPTER 458-61 WAC
THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ITEMS 0 THROUGH 0 ARE FULLY COMPLETE.
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Name
Name
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Street c7 t 1. /' j.'..
Street
City t State Zip C _ City State I . (l
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NEW OWNER'S Name t ` n t`y 1-ZJ `_ :;U tit:, ALL TAX PAR EL NUMBERS
PERMANENT ADDRESS
FOR ALL PROPERTY Street `? 71 iv` Y il 1
TAX RELATED
CORRESPONDENCE r"r:;ton „','+. ),,
City/State Zip
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LEGAL DESCRIPTION OF 'PROPERTY SITUATED IN UNINCORPORATED Je'^fir :611
COUNTY OR IN CITY OF
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- tion, u6 1.er l:�lat r'_u : .,,.' ' t ,o1__; t.a � et 1-A,;,
—lyt - recur""t:_ .=t` Jeffer.;on -..,ounty, t t, G,,ir ,t ;.!11.
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0 Is the property currently: YES NO Q Description of personal property if included i sale(furniture,ap-
Classified or designated as forest land?
Chapter 84.33 RCW ❑ El pliances,etc.) Y '
Classified as current use land(open space,
farm and agricultural,Chapter 84.34 RCW or timber)? El
Exempt from property tax under Chapter If exemption claimed,explain ii ,i r v 1_#
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0
84.36 RCW?(nonprofit organizations) 13r ` t.,,,, -t r 'P. C :), o )t l;e r
c o r ' .v. ' t ;,<: t.. .
Receiving special valuation as historic ❑ LJ
L 1
property under Chapter 449,Laws of 1985?
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Type Property: it] land only Elland with new building Type of Document y, µ
(�1
Date of Sale or Conveyance ~'Y . 1-5i1(4L 6
Elland with previously CI land with mobile home Gross Sale Price 1/ J•'
used building $ "`' "
SEE TAX OBLIGATIONS ON REVERSE SIDE Personal Property(deduct)2/ $ Orr �•)
OTaxable Sale Price $ -'(- 0 p-`«
a
(RCW 84.33 or RCW ,84.34) Excise Tax State 3/ da
(1) NOTICE OF CONTINUANCE $ Ch
Local 4/ $ ),C/
If the new owner(s) of land that is classified or designated as current use or Delinquent Penalty 5/ $ • {%
forest land wish(es)to continue the classification or designation of such land, +Vl
the new owner(s) must sign below. If the new owner(s) do(es) not desire to Total Tax Due $ r u
continue such classification or designation, all compensating or additional tax (SEE 1-5 ON REVERSE SIDE)
calculated pursuant to RCW 84.33.120 and 140 or RCW 84.34.108 shall be due O
and payable by the seller or transferor at the time of sale. To determine if the
land transferred qualifies to continue classification or designation, the county AFFIDAVIT
assessor must be consulted.All new owners must sign. I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE
STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND
This land 0 does ❑ does not qualify CORRECT (see#6 on reverse for enalti,$). ,.
for continuance. DEPUTY ASSESSOR �„ P_ /
DATE r f .
SIGNATURE: /F.-f(�i C*'f!!7(,i r / '/14/is
(2) NOTICE OF COMPLIANCE(Chapter 449,Laws of 1985) �V r < /`} { / /� Ic t� >
NAME (print):
If the new owner(s) of property with special valuation as historic property A/21(4 1
wish(es)to continue this special valuation the new owner(s)must sign below.If DATE & PLACE OF SIGNING: r'"N`
the new owner(s)do(es)not desire to continue such special valuation,all addi C L- L Ll )
tional tax calculated pursuant to Chapter 449, Laws of 1985,shall be due and SPECIFY (circle): grantor/grantee/grantor's a
payable by the seller or transferor at the time of sale. gent/grantee's agent
i
Address of residence or place of business o-person signing (specify):
(3) OWNER(S)SIGNATURE
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The following optional questions are requested by RCW 82.45.120
Is property at the time of sale: e. oes conveyance involve a Made,partial
interest corporate affiliates,related parties 1❑ 2 El
a. Subject to elderly,disability,or physical improvement trust,receivership or an estate?
exemption? 1❑ 2 0 f, Is the grantee acting as a nominee for a third
1❑ 2❑
b. Does building, if any, have a heat pump or solar
party?
heating or cooling system? 1❑ 2 El
g. Principal use:
c. Does this conveyance divide a current parcel of land? 1❑ 2 El
1 0 agricultural 2 0 condominium 3 El recreational
d. Does sale include current crop or merchantable 1 El 2 El 4 El apt(4+ units) 5 0 industrial 6 El residential
timber?
7 Elcommercial 8 D mobile horn
9 ❑ tim '
FOR TREASURER'S USE ONLY
P
1-71
FORM REV 64 0030 (Rev. 10/85) -465- COl1NTYA$SESSO