Form 84 0001be (A) - Real Estate Excise Tax Affidavit Controlling Interest Transfer Return
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4Mail Completed Form To:
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Washington State Department of Revenue
Washington State
REAL ESTATE EXCISE TAX AFFIDAVIT
Department of Revenue
Special Programs Division
CONTROLLING INTEREST TRANSFER RETURN
PO Box 47464
CHAPTER 82.45 RCW – CHAPTER 458-61A WAC
Olympia, WA 98504-7464
This form must be used for reporting transfers of controlling interest and for buyer disclosure to the Department of Revenue. (Use Form No. 84-0001A for
reporting transfers by deed or real estate contract to the county treasurer/recorder of the county in which the real property is located.)
1
TRANSFEROR
2
TRANSFEREE
Name
Name
Street
Street
City
State
Zip
City
State
Zip
Unified Business Identifier No.
Unified Business Identifier No.
-
Federal Identifier No.
-
Federal Identifier No.
Percent of Entity Ownership Sold
%
Percent of Entity Ownership Purchased
%
Attach list for multiple sellers or buyers; include percentage sold or bought for each.
3
AFFIDAVIT
AFFIDAVIT
I certify under penalty of perjury under the laws of the state of
I certify under penalty of perjury under the laws of the state of
Washington that the information on this return is true and correct.
Washington that the information on this return is true and correct.
Signature of
Signature of
Transferor/Agent
Transferee/Agent
Name (print)
Name (print)
Date & Place of Signing
Date & Place of Signing
Telephone Number
Telephone Number
4
Name and address of entity whose ownership was transferred:
Type of entity (check one):
Name
Corporation
Street
Partnership
City
State
Zip
Trust
Unified Business Identifier Number
Limited Liability Company
-
Federal Identifier Number
5
Attach list of other entities which are owned 50% or more by the entity which was transferred. List names and
addresses and attach real property disclosure for these “second-tier” entities.
6
REAL PROPERTY VALUES: (Attach extra sheet, if necessary)
A.
Total true and fair value of real property in the state of Washington owned by the entity (named in Block #4) whose ownership
was transferred or other entities which are owned 50% or more by the entity which was transferred (named in
Block #5): $ _____________________ . The measure of the tax is the true and fair value of the real property. Please see section on
“Measure of the tax,” on the reverse side of the form.
B.
List real property parcel numbers and values by 4-digit location codes. You may obtain the location codes from the Real Estate
Excise Tax Rates Form (form 84 0013) at the Department of Revenue web site at
Location
County Tax
True & Fair
Location
County Tax
True & Fair
Code
Parcel No.
Value
Code
Parcel No.
Value
$
$
$
$
$
$
$
$
$
$
$
$
7
TAX COMPUTATION:
1.
Using the Real Estate Excise Tax Rates Form, multiply the total true and fair value of all real property in the state of Washington
(from 6a above) by the state tax rate. Show the total state tax on line 1, below.
2.
Using the same tax rates form, compute the local tax for each location code; multiply the total true and fair value for property
within each location code by the local tax rate for that location code. Show the total local tax on line 2, below. Attach a copy of
your worksheet.
3.
If you owe interest or penalty, write that amount on the appropriate line below. (See RCW 82.45.100)
4.
Add lines 1 through 5; this is your total due. Make check or money order payable to Washington State Department of Revenue.
Date of Transfer
If tax exemption is claimed, provide reference to WAC Title and Number
$
0.00
Department of Revenue Use Only
1. State Tax ........................................
$
2. Local Tax .......................................
$
3. State Delinquent Interest................
$
4. Local Delinquent Interest...............
$
5. State & Local Delinquent Penalty..
TOTAL DUE
$
0.00
Please See Information On Reverse
REV 84 0001Be (a) (12/29/06)
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