Form Rev 84 0001be - Real Estate Excise Tax Affidavit Controlling Interest Transfer Return
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Mail Completed Form To:
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.)
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TRANSFEROR
TRANSFEREE
(Attach a list for multiple transferors including percentage sold)
(Attach a list for multiple transferees including percentage bought)
Name
Name
Street
Street
City
State
Zip
City
State
Zip
Tax Registration Number
Tax Registration Number
--
--
Federal Identifier Number
Federal Identifier Number
-
-
Percent of Entity Ownership Sold
%
Percent of Entity Ownership Purchased
%
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
Type of entity (check one):
3
Name and address of entity whose ownership was transferred:
Name
Corporation
Street
Partnership
City
State
Zip
Trust
Tax Registration Number
Limited Liability Company
Federal Identifier Number
-
4
Attach a list of names, addresses, and relationships of all entities affected by this transfer.
5
REAL PROPERTY VALUES: for on-line tax computation, fields A, B, and C are required.
A. Select location. For assistance finding a location, use the link below.
B. Enter County Tax Parcel number.
C. Enter the True & Fair Value of real property. (RCW 82.45.030(2))
A.
B.
C.
Local
State Excise
Local
City/County
County Tax Parcel
Subtotal
Tax Rate
City/County
Location
True & Fair Value
Tax Rate
No.
( .0128)
Tax
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
Select Location
0.00
0.00
$0.00
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TAX COMPUTATION:
1.
If you owe interest or penalty, enter the amount in line 3, 4, and 5. (RCW 82.45.100)
2.
If you need assistance in completing this form, please contact the Special Programs Division,
Department of Revenue at (360) 570-3265.
3.
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
$
1. State Tax ........................................
$0.00
Department of Revenue Use Only
$
2. Local Tax .......................................
$0.00
$
3. State Delinquent Interest................
$
4. Local Delinquent Interest...............
$
5. State & Local Delinquent Penalty..
$
TOTAL DUE
$0.00
Please See Information On Reverse
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REV 84 0001Be (6/28/12)
without the full version of Adobe Acrobat. If you are not using the full version of
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