Department of 
Revenue

Washington State

PLEASE TYPE OR PRINT

REAL ESTATE EXCISE TAX AFFIDAVIT
CHAPTER 82.45 RCW CHAPTER 458-61A WAC

 

This foi?m is your receipt
when stamped by cashier.

THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED
(See back of last page for instructions)

Check box it partial sale of property

Name Bill Nelson

 

If multiple owners, list percentage of ownership next to name.

Name Crown Columbia Water Resources, LLC 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


2 Mailing Address 21 Sunrise CT Mailing Address lildUSIJ'lal Park 3803 N. Rd
0? City/State/Zip Rock Island. WA 98850 Cityr'StateIZip Spokane Valley, WA 99216
Phone No. (including area code) (509) 679-2974 Phone No. (including area code)(509l 924-1720 1
Send all property tax correspondence to: Same as ?5t all-llu?ayicigi Eiffkniilo: 1:301:21 [Lafiragcount Listi assessed value(s)
Name 21222220001 521260000
Mailing Address 21222220002 $100,400.00
Cityr?State/Zip 21222220003 5129130000
Phone No. (including area code) 21222220004 $101,506.00

 

 

 

 

 

 

 

Street address of property: 21 Sunrise Ct Rock Island. WA 98850

 

This property is located in Douglas County

EICheck box if any of the listed parcels are being segregated from another parcel, are part ot'a 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)

0.560fs and 1003f from water rights referenced by surface water certi?cate 84-241660 . Douglas County Conservancy Board Application
No. DOUG 17-01. Department of Ecology Change Application No. and Department of Ecology Modi?cation Letter dated
02/07/2019 which are appurtenant to Portions of W112 W114 Sec. 21 T21 R22EWM

 

Select Land Use Code(s):
I80 - Water or Mineral rights I

 

 

enter any additional codes:
(See back of last page for instructions)

 

 

F31 all personal property (tangible and intangible) included in selling
price.

We

APR 1 2 2019

 

YES NO
Is this property exempt from property tax per chapter 
84.36 RCW (nonpro?t organization)?

YES NO
Is this property designated as forest [and per chapter 84.33 
Is this property classi?txi as current use (open since, farm and El
agriculturaL or timber) land per chapter 84.34?
Is this property receiving special valuation as historical property 

per chapter 84.26 
Ii'any answers are yes, complete as instructed below.

1) NOTICE OF (DNTINUANCE (FOREST LAND 0R CURRENT USE)
NEW To continue the current designation as forest land or
classi?cation as cunent 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. If the
land no longer quali?es or you do not wish to continue the designation 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 ot?sale. (RCW
84.33.140 or RCW 84.34.108). Prior to signing (3) below. you may contact
your local county assessor - more information.

This land Ddoes 0' not quantinuance.

DEPUTY ASSESSOR DA 

(2) NOTICE OF COMPLIANCE (HISTORIC PROPERTY)
NEW To continue special valuation as historic property.
sign (3) below. lfthe new owner(s) does not wish to continue, all
additional tax calculated pursuant to chapter 84.26 RCW, shall be due and
payable by the seller or transferor at the time of sale.

OWN SIGNATURE

ontu.

PRINT NAME

      
   

    
 
 

 

If claiming an exemption. list WAC number and reason for exemption:

WAC No. (Section/Subsection) nla

Reason for exemption
nla

Type of Document Water Right Statutory Warranty Deed

 

Date of Document 3113MB

 

 

 

 

 

 

 

 

 

 

 

 

Gross Selling Price 340300-00
*Pcrsonal Property (deduct) 5
Exemption Claimed (deduct) 

Taxable Selling Price 34030000

Excise Tax State 4.35200

Local 3 850.00
*Delinquent Interest: State 3
Local 5
*Delinquent Penalty 3

Subtotal 5 5,202.00

*State Technology Fee 5.00
*Affidavit Processing Fee 

5,207.00

Total Due 

 

I
A MINIMUM OF $l0.00 IS DUE IN TAX
INSTRUCTIONS

 

 

CERTIFY UNDER PENALTY OF PERJURY
Signature of
Grantor or Grantor?s Agent

 
  
 

Name (print)
Date city of signing: 5/21, Ml?

REV 84 1)

THAT THE FOREGOING IS TRUE AND CORRECT.

Signature of
Grantee or Grantee?s Agent

Name (print) (mac (VIA or

 

Date city ofsigning: 5t (Eli 

Perjury: Perjury is a class felony which is punishable by imprisonment in the state correctional institution for a maximum term of not more than ?ve years. or by a
line in an amount ?xed by the court of not more than ?ve thousand dollars 

THIS SPACE - TREASU USE ONLY

COUNTY TREASURER
2 21/2144? [th60

,000.00), or by both imprisonment and ?ne