Escrow Number: LTC-14835 Escrow Officer: Brandi K. Jensen Buyer/Borrower: Carol Lynn Montgomery Seller: Property: LAND TITLE & ESCROW COMPANY OF ISLAND COUNTY 7202 2676 St. N.W., Suite 101 / P.O.Box 1769 Stanwood, WA 98292 Tel: (360) 629-9737 • Fax: (360) 629-2152 BUYER/BORROWER STATEMENT Estimated Gilbert A. Powell and Patricia A. Powell Title Order Number: 5207133715 Date: 12/21/2015 - 2:46:01PM Closing Date: 12/23/2015 DESCRIPTION DEBITS CREDITS TOTAL CONSIDERATION I 05,000 00 Earnest Money 5,000.00 PRORATIONS/ADJUSTMENTS: Property Tax @ 231.37 per 12 month(s) 12/23/2015 to 12/31/2015 5.71 TITLE CHARGES Deed Recording Fee: Old Republic Title & Escrow 79.00 ESCROW CHARGES TO: Land Title & Escrow Escrow Fee 590.00 Escrow Fee - Tax 51.92 Courier Fee 10,i;b 42131: BALANCE DUE TO ESCROW 100,759.27 TOTALS ,1er Carol ynn naty 105,759.27 105,759.27 THESE FIGURES ARE ESTIMATED AND ARE SUBJECT TO CHANGE PRIOR TO CLOSING/DISBURSING OF FUNDS EFTA01121771 When recorded return to: ery Filed for record at the request of Land Title and Escrow of island Co. Escrow No.: LTC-14835 Title Order No.: 5207133715 Statutory Warranty Deed Grantor(s): Gilbert A. Powell and Patricia A. Powell, husband and wife Grantee(s): Carol L no Mont omer Abbreviated Legal: Assessor's Tax Parcel Number(s): 011504-000-006-00 THE GRANTOR Gilbert A. Powell and Patricia A. Powell, husband and wife for and in consideration of ONE HUNDRED FIVE THOUSAND AND NO/100 in hand paid, conveys and warrants to Carol Lynn Montgomery, a single person the following described real estate, situated in the County of Snohomish, State of according to the plat thereof recorded under Recording No. records of Snohomish County, Washington. Situate in the County of Snohomish, State of Washington. Subject to all covenants, conditions, restrictions, reservations, agreements and easements of record, if any. Dated J}eceinbeq 21, STATE OF COUNTY OF SS: Patncia A. Powell h } I certify that I know or have satisfactory evidence that Gilbert A. Powell and Patricia A. Powell the person who appeared before me, and said person acknowledged that they signed this instrument and acknowledge it to be their free and voluntary act for the uses and purposes mentioned in this instrument. Dated: Notary Public in and for the State of Residing at My appointment expires: LPB 10-05(i-I) Page I of I EFTA01121772 Signature of Grantor or Grantor's Agent Name (print) Gilbert A. Powell Department ea Revenue rea-Wosheyton State PLEASE TYPE OR PRINT REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt LTC-14835/5207133715 CHAPTER 82.45 RCW - CHAPTER 458-61A WAC when stamped by cashier. THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ON ALL PAGES ARE FULLY COMPLETED (See back of last page for instructions) ❑ Cheek box if artist sale of property If multiple owners, list percentage of ownership next to name 7 Gilbert A. Powell and Patricia A. Powell, husband and Name wife . Name Carol Lynn Montgomery, a single person in C § lc ur to ro C Mailing Address Mailing Address City/Stateaip City/StatelZip Phone No. (including area code) Phone No. (including area code) il Name Mailing City/State/Zip Phone Send an property tax correspondence to: XX Same as Buyer/Grantee Us all real and personal tax parcel account numbers — check box if personal property O O List assessed value(s) AV Address , O No. (including area code) ❑ gmStreet address of property: This Property is located in O unincorporated Snohomish County OR within O city of Stanwood O Check box if any of the listed parcels are being segregated from another parcel, are pan of boundary line adjustment or parcels being merged. Legal description of property (if more space is needed, you may attach a separate sheet to each page of the affidavit) according to the plat thereof recorded under Recording No. recor s o nohomish County, Washington. Situate in the County of Snohomish, State of Washington. El Select Land Use Code(s): a List all personal property (tangible and intangible) included in selling 91 price. enter any additional codes: (Sec back of last page for instructions) Is this property exempt from property tax per chapter 84.36 RCW (nonprofit organization)? YES ,NO O Is this property designated as forest land per chapter 8433 RCW? Is this property classified as current use (open space, farm and agneuhural, or timber) land per chapter 84.34? Is this prupwry receiving special valuation as historical property per chapter 84.26 RCW? If any answers are yes, complete as instructed below. (1) NOTICE OF CONTINUANCE (FOREST LAND OR CURRENT USE) NEW OWNER(S): To continue the current designation as forest land or classification as current use (open space, farm and agriculture, or timber) land, you must sign on (3) below. The county assessor must then determine if the land transferred continues to qualify and will indicate by signing below. If the land no longer qualifies or you do not wish to continue the designation or classification, it will be removed and the compensating or additional taxes will be due and payable by the seller or transferor at the time of sale. (RCW 84.33.140 or RCW 84.34.108). Prior to signing (3) below, you may contact your local county avensor for more information. This land 0 does O does not qualify for continuance YES NO O ❑ )5( DEPUTY ASSESSOR DATE (2) NOTICE OF COMPLIANCE (HISTORIC PROPERTY) NEW OWNER(S): To continue special valuation as historic property, sign (3) below. If the new owner(s) do not wish to continue, all additional tax calculated pursuant to chapter 84.26 RCW, shall be due and payable by the seller or transferor at the time of sale. (3) OWNER(S) SIGNATURE PRINT NAME If claiming an exemption, list WAC number and reason for exemption: WAC No. (Section/Subsection) Reason for exemption Type of Document Date of Document Statutory Warranty Deed December 21, 2015 Gross Selling Price $ 'Personal Property (deduct) S Exemption Claimed (deduct) $ Taxable Selling Price S Excise Tax: State $ Local $ 'Delinquent Interest: State S Local $ 'Delinquent Penalty $ Subtotal $ *State Technology Fee S 'Affidavit Processing Fee S Total Due S 105,000.00 No 105,000.00 1,344.00 525.00 1,869.00 5.00 1,874.00 A MINIMUM OF $10.00 IS DUE IN FEE(S) AND/OR TAX °SEE INSTRUCTIONS I CERTIFY NDER P ALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT _ , I al Oat-- Date & city of signing: Signature of Grantee or Grantee's Agent Name (print) Carol Lynn Montgomery Date & city of signing Perjury: Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a maximum tam of not more than five years, or by a fine in an amount fixed by the court of not more than five thousand dollars ($5,000.00), or by both imprisonment and line (RCW 9A.20.020 (IC). REV 840001a (1/7/13) THIS SPACE —TREASURER'S USE ONLY COUNTY TREASURER EFTA01121773