HomeMy WebLinkAbout137376 °ePanmentof Real Estate Excise Tax Affidavit (RCW 82.45 WAC 458-61A) , , -
Revenue Only for sales in a single location code on or after January 1.2020.
Watitbigen StateThis affidavit will not be accepted unless all areas on all pages are ftiliy completed.
This form is your receipt when stamped by cashier.Please type or print.
Form�84 0001a
0 Check box if the sale occurred in more than one location code. 0 Check box if partial sale,indicate% sold.
List percentage of ownership acquired next to each name.
I Seller/Grantor 2 Buyer/Grantee
Name Judith K.Hoyle,as her separate property and Patricia J. Name Robert L.Hoyle III,married only to Judith K.Hoyle on January 3,
Cosner,as her separate property 2020 date of acquiring title,
Mailing address P.O.Box 361 Mailing address P.O.Box 361
Citydstatrhip Chimacum,WA 98325 City/atatdzip Chi mecum,WA 98325
Phone(including area code) (360)531-2337 Phone('including area code) (360)531-2337
3 Send all property tax correspondence to:❑Same as Buyer/Grantee List all real and personal property tax Personal Assessed
parcel account numbers propene value(*)
Name Robert L.Hoyle,III 983 400 712/37560 0 58,100.00
983 400 713/37561 0 547,052.00
Mailing address PO Box 361 0 50.00
City/statehip Chimacum,WA 98325
4 Street address of property 21 E.Spruce Street,Port Ludlow,WA 98365
This property is located in Jefferson (for unincorporated loprdorat please select your county)
❑Check box if any of the listed parcels are being segregated from another parcel,arc part of a boundary line adjustment or parcels being merged.
Legal description of property(if you need more space,attach a separate sheet to each page of the affidavit).
Lots 13 And 14,BIock 7 of Paradise Bay Estates,as per plat recorded in Volume 4 of Plats,page 5,records of Jefferson County,
Washington.
Situate in the County of Jefferson,State of Washington.I
5 91 7 List all personal property(tangible and intangible)included in selling
Enter any additional codes 11 price.
(see back of last page for instructions)
Was the seller receiving a property trot exemption or deferral
wider RCW 8436,8437,or 8438(nonprofit mg,senior
citizen or disabled person,homeowner with limited income)? ❑Yes I8)No If claiming an exemption,list WAC number and reason the exemption.
Is this property predoininantly used for timber(as classified under WAC number(section/subsection) 458-61A-217(1)
RCW 84.84 and 84.33)err agriculture(as classified under RCW
84.34.020)?See ETA3215. ❑Yes®No Reason foreremption Re-record QCD AFN 629588/REET#133778
Ityes,complete the predominate we calculator(see instructions for with corrected notary acknowledgment for Patricia J.
*salon Cosner since notary Judith K. Hoyle was also a party to
the conveyance
6 la this property designated as forest land per RCW 84.33? ❑Yes®No
Is this property classified as current use(open space,farm
and agricultural,or timber)land per RCW 8434? 0 Yes®No Type of document Quit Claim Deed
Is this property receiving special valuation as historical
property per RCW 84.26? ❑Yes IN No Date of document August 4,2021
if any answers are yes,complete as instructed below. Gross selling price S 0.00
(1)NOTICEOFCONflNUANCE(FORESTIANDOR CURRENT USE) *Personal property(deduct) S
NEW OWNER(S):To continue the anent designation as forest land or classification as Exemption claimed(deduct) S
cumuli we(open space,firm and agriculture,or timber)land,you must sign on(3) Taxable selling price S 0.00
below.The county assessor must then determine if the laid transferred continues t0
quddy and will indicate by signing below. if the land no longer qualifies or you do not Excise tax: state
wish to condnue the designation or classification,it will be removed and the Len ttrmn S500,000.01 at 1.1% S 0.00
compesaaating or additional taxes will be due annd payable by die seller or transferor at
the tine of sale. (RCW 8433.140 or 8434.108).Prior to signing(3)below,you may From$500,000.01 to S1,500,000 at 1.28% S
contact your local county assessor for more irdotnation. From 31,500,000.01 to 53,000,000 at 2.75% S
This land: ❑ does 0 does not qualify for oontinuance. Above$3,000,000 at 3.0% S
Agricultural and timberland at 1.28% S
Total excise tax:state S 0.00
Deputy assessor signature Date Local S 0.00
(2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) *Delinquent interest state S
NEW OWNER(S):To continue special valuation as historic property,sign(3) Local S
below.If the new owner(s)doesn't wish to continue,all additional tax calculated *Delinquent penalty S
pursuant to RCW 84.26,shall be due and payable by the seller or transferor at the Subtotal S 0.00
tune of sale. *State technology fee S 5.00
(3) NEW OWNER(S)SIGNATURE Affidavit processing fee s 5.00
Total due S . 10.00
Signature Signature
A MINIMUM OF S10.00 IS DUE IN FEE(S)AND/OR TAX
*SEE INSTRUCTIONS
Print name Print name
8 I CERTIFY UNDER PENA TY OF PERJURYTIIAT THE FOREGOING IS TRUE AND CORRECT
glIT/17,
Signature of grantor or agent LC.".M Signature of grantee or agent y , l/
Name(print) Patricia J.Cosner Name(print) Robert L.HoyIII
Date&city of signing: s / ale/6L/171 w.due wA- 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 more than
five years.or by a fine in an amount fixed by the court of not more than 55,000,or by both imprisonment and fine(RCW 9A20.020(i c)).
To ask about the availability of this publication in an alternate format for the visually impaired,please call 360-705-6705.Teletype
(TTY)users may use the WA Relay Service by calling 711.
REV 84 0001a(11/06/2020) THIS SPACE TREASURER'S USE ONLY COUNTY TREASURER //��
Print on legal size paper. Y
Page 1 of 6
1006685 137376 *08/13/2021 $10.00* 1
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