STATE OF WASHINGTON DEPARTMENT OF NATURAL RESOURCESPage __ of__

FIRE PROTECTION ASSESSMENT (FPA) REFUND FORM

MUST BE SIGNED AND POSTMARKED BY DECEMBER 31 OF THE CURRENT YEAR.

FOR OWNERS OF MULTIPLE PARCELS. (List only parcels less than 50 acres each.)

INSTRUCTIONS ON BACK

FOR LANDOWNER USE: (See #4 and #5 on back) (Additional pages may be attached)

NAME: (Please Print Legibly or Type)
Mailing Address:
City: / State/Zip: / Phone:
TAX YEAR: / Email:
PARCEL NUMBER
See #6 on back / FPA ACRES
See #7 on back / AMOUNT FPA PAID
See #8 on back

All information is correct to the best of my knowledge. Inaccurate information may be cause for rejection.

Signed______Date ______

FOR COUNTY TREASURER: Forest fire protection has been paid in full and FPA acreage listed above is correct.

County

/ Stamp or Signature of County Treasurer / Date
FOR DNR USE:
Date refund form received: / Total FPA Acres:
Approved by: / Amount FPA Paid:
Check Number: / Amount FPA Retained:
Date Paid: / Amount FPA Refund:

INSTRUCTIONS

Per RCW 76.04.600, this assessment is a fee levied on forest and unimproved lands that DNR protects from wildfire. Assessment revenues are used to purchase wildfire engines, hire and train wildfire personnel, provide forest fire detection systems, purchase wildfire equipment and provide office space and work station in various strategic locations near protected areas. If a wildfire starts, DNR is there to suppress that fire at no additional cost to you if negligence is not involved.

1.Taxes must be paid in full before submitting.

2.This form must be submitted annually.

3.List only ONE County per form.

4.For purposes of the multiple parcel refund, to qualify, the name on each parcels tax statement must be identical.

5.Enter name and address of landowner as shown on tax statements. Sign form where indicated. Your signature verifies that all information is correct.

6.Enter parcel numbers as shown on tax statements.

7.Enter only those acres subject to fire protection assessment. Your County Assessor may supply a listing of those acres if unimproved acres are not indicated on tax statements. Maximum parcel size is 50 acres or under. Do not include any parcels larger than 50 acres.

8.Enter fire protection assessment paid, less the $.50 county fee.

9.Hand carry or mail this form to your County Treasurer for verification of payment of taxes in full. County Treasurer's signature or stamp must appear on this form.

Form must be signed and postmarked by December 31 of the current year.

10.County Treasurer will forward to: Department of Natural Resources, Resource Protection Division, PO Box 47037, Olympia WA 98504-7037.

Department of Natural Resources (DNR) will compute the refund and process payment. You will receive a partial refund of all assessments paid. Depending on total acreage, a minimum of one assessment will be retained by DNR and the balance refunded.

Questions or concerns, contact the Department of Natural Resources, Resource Protection Division, at 1-360-902-1300.

Allow six to eight weeks for processing.

This form may be copied prior to the Treasurer’s signature and updated for use next year.

refund form 3/14/2000