Form Rev 84-0001b - Real Estate Excise Tax Affidavit/return - 1998
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1
2Mail Completed Form To:
Washington State Department of Revenue
Department of Revenue
REAL ESTATE EXCISE TAX AFFIDAVIT/RETURN
Miscellaneous Tax Section
Form No. 84-0001B
PO Box 47464
CHAPTER 82.45 RCW - CHAPTER 458-61 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 of deed or real estate contract to the county treasurer of the county in which the real property is located.)
1
2
TRANSFEROR
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 Bought
%
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
Partnership
Street
Trust
City
State
Zip
Limited Liability Company
Unified Business Identifier Number
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: $
.
B. List real property parcel numbers and values by location codes from the State and Local Real Estate Excise Tax Rate
Schedule (Form REV 84 0013) at your county treasurer’s office or Department of Revenue (address above).
Location
County Tax
True & Fair
Location
County Tax
True & Fair
Code
Parcel No.
Value
Code
Parcel No.
Value
$
$
$
$
$
$
$
$
$
$
$
$
7
TAX COMPUTATION:
1. Using the State and Local Real Estate Excise Tax Rate Schedule, 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 rate schedule, 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
.
Department Of Revenue Use Only
1. State Tax .....................................
$
2. Local Tax ....................................
$
3. State Delinquent Interest..............
$
4. Local Delinquent Interest.............
$
5. State Delinquent Penalty..............
$
$
TOTAL DUE
Please See Information On Reverse
REV 84 0001B-1 (6-08-98)
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