Dispostion Certification For Export Restricted Timber
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1
2Washington State
Department of Revenue
Dispostion Certification for
Forest Tax Program
PO Box 47472
Export Restricted Timber
Reset This Form
Olympia WA 98504-7472
1-800-548-8829
Contracting/Selling Agency:
Sale Name
Agency Contract Number:
DNR Region
County(s):
Forest Practices Application Number:
Assigned Log Brand Description:
Registered Log Brand Number
The purchaser states the following is a true and complete statement of the disposition of the timber
harvested under this contract. Making false statements is punishable by a gross misdemeanor
per RCW 9A.72.040.
Company
Volume
Volume
Name
Location
Species
(MBF)
(Tons)
TOTALS
0
0
Company Name
UBI Number
Representative’s Name
Representative’s Title
Representative’s Signature
Date
Print This Form
REV 62 0084e (3/6/12)
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