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<br /> PLI'ASC TYPE OR PHINT REAL ESTATE EXCISE TAX AFFIDAVIT This form is ywr mccipt whcn wmpcd
<br /> Form No. 84 OOOIA bY cashicr.
<br /> CHAPTER 82.45 RCW-CHAPTER 456-61 WAC
<br /> For Usc at County Tmasurera Officc
<br /> (Use Form No. 84�WOIB for ReponinQ Tnnsfcrs of Comrolling Imcrost of En1iry Owncrship w Ihc Dcpanmcnt of Re�enuc)
<br /> THIS AFFIDAVIT WILL NO'f BE ACCBPI'LD UNLFSS ALL ITIiMS ARE FULLY COMPL�TED
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<br /> Name Namc
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<br /> `"c�,7 City Stetc Zip tD Ciry State Zip
<br /> ADDRFSS TO SEND ALL PRpPER7Y TAX RELATED CORRFSPONDENCE ALL TAX PARCEL NUMBERS UKT.Yi � "�� 's%
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<br /> Ciry/Stotc Zip ' � � x:> � t . :%
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<br /> � LECAL DESCRIPTION OF PROPERTY SITUATED IN O UNMCORPORATED COUNTY O OR IN CITY OP ���'✓�'�'•=t�
<br /> 45%J !���i�';1 `i••ivr•� ,?•rrt:ett t111 `.II;ZB:i
<br /> Strecl Address (if property is improvcd):
<br /> .. .. , :'� I'. ..,;i:.,.
<br /> Das this transkr of re�l propeny rcflcct thc transkr or ocquisition of Ihc rnntmlling intcrcst in an cntity with un intcrest in�cal propcny in this sta�c7 Yes� No0
<br /> If yea, Ihis tnnsfcr of conlrolling intcrcst must alao bc rcportcd to Ihc Dcpunmcnt of Rcvenue within fivc days of Ihe salc on Frorm No. 84 OOOI&
<br /> � Is this propcny currcntly: YES I10 �p�uription of langiblc personal property if includcd in sale (furnilurc,
<br /> Classificd or dcsignntcd ns forcu land7 ❑ � aPP���nccs, ctc.)
<br /> Chaptcr 84.33 RCW n�+1
<br /> Clauified as current uu land (open space, farm ❑ �
<br /> and agricullural, or�imbcr)?Chuptcr 84.34 RCW
<br /> ExemPt from propeny laz undcr nonprofit � � If cxcmption clai�p�t4W���umbcr and title.
<br /> orgnmzations? Chaptcr 84.36 RCW '
<br /> W�eiving spccial vnluntion as hiuoric � [] w'AC Numbcr
<br /> propeny undc�l Chaprer&i.25 RCW WpC Tidc ��v:�r n:�ant, tru„3fcrs tn or Prom
<br /> Property Typc: ❑ land only O lend with new building � e�' itu, , c. x,i.t :a
<br /> f3 iand with prcviously ❑ land witt, mobilc homc 7ypc of Documcnt titntutn��� ��la.�����nt�r T�,•�+r1
<br /> � � used building Datc of Document �����4 �
<br /> � (1) N07'IC8 (�F CONTINUANCB (RCW 8433 or RCW 84.34) Gross Sulc Price S 1�
<br /> If ihe new owner(s)of land that is classified or designuted as current use Personal Property (deduct) S
<br /> orforestlandwishtocantinuethcclassificvionordesignmionofwchland, 7yxablcSalcPricc E
<br /> the ncw owncr(s) muu sign bclow I[thc new owncr(s)do not dcsi�e to Excisc Tax State S
<br /> continue such clnssificalion or dcsignation,all compensating or nddi�ional
<br /> ' mx calculated purwant ro RCW 84.33.120 and UO or RCW 84.34.108 shall Local S
<br /> ; be due anl p�nble by�hc sellcr or transfcror at the timc of selc.Thc county p��inqucnt Intcmu: Smte S
<br /> asseuor must dctermine if thc Iand transkrrcd qualifios to continuc �a� s
<br /> classification or designWion nnd must so indicate bclow.Signa�urcs do not
<br /> ncccssarily mcan thc land will �cmain in classifica�ion or dcsignotion. If ���nqucn� Pcnnity: Stntc S
<br /> it m longer qualifics, it will bc�cmovcd and ihc compcnsating taxes will 1bte1 Due S
<br /> � bc applicd. All new owncrs must sign. THERE IS A SZ.00 FEE FOR PROCESSING THIS FORM IP NO TAX IS DUE. '
<br /> This Iund ❑does Q�locs not quaiify for continuance. � AFFIDAVIT
<br /> Date I ccrtify under penalty of perjury under the laws of the state oP
<br /> DEPUTY ASSESSOR Washington that the foregoing is true and correct.
<br /> (2) N07'ICE OF COMPLIANCE(Chaptcr 84.26 RCV�ry �
<br /> if thc ncw owncr(s)of ro n with s cial wluation as historic ro n Signat4_� of
<br /> P a Y a P a Y• Cront�/Agent �'�'� � -�-
<br /> wish lo continuc this spcciul v�luation the ncw owncr(s)must sign bclow. - ;
<br /> If�he new owner(s)do not desirc to continuc such special valuation, all Name (p�int) � ' �"•
<br /> odditional tax cnlculatcd purounnt to Chaptcr 84.26 RCW,shall bc duc and '" - . � . - _ � t
<br /> payablc by thc ullcr or trnnskror ut thc time of salc. Da[e & Place of Signing ` "'
<br /> (3) OWNER(S) SIGNATURE Signaturc of.. _
<br /> Grantee/Agenf
<br /> Name (nrint) ' �
<br /> Date & Place of Signing
<br /> (i/t3/'�,f� i?v��rc:tt 'd_l
<br /> I�PERJURY Perjury is a class C felony which is punishable by imprisonment in a state correctional institution for a maximum
<br /> te�'(��Ftnqr�l�+aq�yg.years, or by a fine in an amount fixed by the court of not mnre than five thousand dollars(55,000.00),
<br /> :G2.90�Yi'p�;�t;�;��fsSnt�P�t�-and fine (RCW 9A.20.020 (1C)).
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<br /> DISfRIDPJ�"i�Nl!�r6fi�inal - County Trcasurcr Ist Copy - Department of Rcvcnuc 2nd Copy - County Assessor 3rd Copy -Taxpayer
<br /> ����J J y� iJ�� FOR TREASURER'S USE ONLY
<br /> 012507 PMNT a7/AI/94 FEE 2.0�i
<br /> KIRaE SIEVERS, SsohamisL (auot� iieusur� '
<br /> "'fORM REV 81 OOOIA(6-9 ) (PD •10-93)
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