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2013, 07-10 MH ApplicationRETURN RECORDED DOCUMENTTO: Cynthia L. DeLeon Attomey at Law 15812 E. Indiana Ave., #200 Spokane Valley, WA 99216 A WASHINGTON STATE OEPARTTIENT OF Manufactured Home at LICENSING Application For full instructions on completing this form, see Manufactured Home Application Instructions, form TD -420-730. Please check one: WITitle Elimination DTransfer In Location Removal from Real Property 10 Manufactured Home TPO/Plate number #73295 Year 1973 Make Ponderosa Length/Width (feet) 68 x 14 Vehicle identification number (VIN) 5143 B Land Manufactured home will be [] Affixed CI Removed Real property Tax parcel no. 55064.0801 Legaj description on page 2 Lot 1 Block 7 Plat name or Section/Township/Range Donwood East Subdivision Quarter/Quarter section El Grantor(s) Registered/Legal Owner(s) — Additional names on page County number No. registered owners 2 No. legal owners 2 Grantee name (if applicable) Name of registered owner Melvin Palanuik Washington driver license or UBI number Name of additional registered owner Linda Palanuik Washington driver license or UBI number Address (Address, City, State, ZIP code) 18520 E. Bridgeport Ave., Spokane Valley, WA 99216 Name of legal owner Same Washington driver license or UBI number Name of additional legal owner Same Washington driver license or 1.1B1 number Address (Address, City State, ZIP code) Same I declare under penalty of perjury under the laws of the state of Washington that I am/we are the registered owner(s) of this manufactured home and the foregoing information is true and correct. x knature of registered owner and title, if applicable Signature of additional registered owner and title, if applicable Notarization/Certification State of County of , Signed or attested before me on (Seal or stamp) by by Print registered owner name Print registered owner name Notary printed or stamped name Notary signature and Title Dealer/county office number or notary expiration TD -420-729 (R/4/12)WA Page 1 013 Continued on next page Manufactured homeTPO/Plate number (from Section 1) 4 Title Company Certification PRINT orTYPE Name of person signing Title company name Position (Area code) Telephone number I certify that the legal description of the land and ownership is true and correct according to the real property records. x Signature Date 5 Building Permit Office Certification Acertify that the manufactured home has been affixed to the real property as described. • a building permit has been issued for this purpose and the attachment will be inspected upon completion. PRINT orTYPE Name of y person signing f14ivi� ,dvrt t-.-(- Building permit office G©5v` Building permit number V.—ez6 Position Pei -e, -,:t- Sp-ect'o-�1'si (Area code) Telephone number cot"- 7N, ---s3 f Li Sig Date 6 Signature of Legal Owner(s) Signature of legal owner indicates consent for Elimination of Title or Removal from real property. x Signature of legal owner and title, if applicable x Signature of additional legal owner and title, if applicable Notarization/Certification State of County of , Signed or attested before me on by by (Seal or stamp) Print registered owner name Print registered owner name Notary printed or stamped name Nptary signature and ]C Title Dealer/county office number or notary expiration 7 Land Description Legal description of land Lot 1, Block 7, Donwood East Subdivision, as per plat recorded in Volume 10 of Plats, page 87, records of Spokane County; Situate in the City of Spokane Valley, County of Spokane, State of Washington. TD -420-729 (R/4/12) WA Page 2 of 3 Continued on next page Manufactured homeTPO/Plate number (from Section 1) Q Dealer Report of Sale - Selling dealer complete this section PRINT or TYPE Dealer name Washington dealer number Date of sale Purchase price Tax jurisdiction/Tax rate ❑ Sales Tax Exempt - Sale to a Certified Tribal member on the reservation (attach notarized statement of delivery). I certify that this information is correct. Any required sales tax has been collected The manufactured home is clear of encumbrances except as shown. X Dealer authorized signature Q County Auditor/Agent Licensing Office Approval (not for use by subagents) PRINT or TYPE Name County office/VFS operator number I certify that the above application appears documentation to proceed with the recording to be completed correctly, and the applicant has sufficient of this form. X Signature Date m Title Fees Filing lee Application Mobile home fee Elimination fee Use tax Subagent fees Total fees and tax $ 0.00 Anyone who knowingly makes a false statement of a material fact is guilty of a felony, and upon conviction may be punished by a fine, imprisonment, or both. RCW 46.12.750 We are committed to providing equal access to our services. TD -420-729 (W4/12)WA Page 3 of 3 if you need accommodation, please call (360) 902-3600 or TTY (360) 664-0116.