Form Rev 84 0004e (A) - Real Estate Excise Tax Refund Request
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4State of Washington
Real Estate Excise Tax Refund Request
Department of Revenue
Special Programs Division
Chapter 82.45 RCW
PO Box 47477
Olympia WA 98504-7477
458-61A WAC
* Submit to County Treasurer
where property is located.
No refund may be made by the department more than four years after the date of sale (RCW 82.45.100).
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Instructions on Reverse Side
Please Type or Print
Claimant
This request refers to taxes originally paid on Affidavit
No.
on
/
/
in the
Address
amount of $
. Claim may be for partial
or entire payment. Amount of tax refund being
requested $
.
Phone
Legal Description of Real Property:
Parcel No.
Request Refund for the Following Reasons:
Affidavit
For Use by County Treasurers Only
I, the undersigned, being first sworn, on oath state that the foregoing
I have reviewed the statements and:
information to the best of my knowledge is a true and correct statement of
have refunded $
of Real Estate
the facts pertaining to the transfer of the above described real estate. Any
Excise Tax on
/
/
.
person willfully giving false information in the petition shall be subject to
am forwarding it with a certified copy of the
the PERJURY LAWS of the State of Washington.
subject Real Estate Excise Tax Affidavit to the
Department of Revenue for refund determination.
Signature
have denied the refund.
(Specify: Grantor/Grantee or Agent for Grantor/Grantee)
Subscribed and sworn to me this
day of
,
/
/
County Treasurer's Signature
Date
20
,
, Notary Public
Department of Revenue Action:
Approved
Initial
in and for the State of
Denied
Date
/
/
residing at
Voucher Number for refund payment
Distribution:
Department of Revenue
County Treasurer
Taxpayer
REV 84 0004e (a) (04/26/07)
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