1995, 08-04 Dept of Licensing MH AppYY1] Dse-cfOWSi1rNGTON MANUFACTURED HOME
ICEnS®nG APPLICATION
RECORDER'S CLOCK
FILED AT THE REQUEST OF:
NAME
ADDRESS
Please check one
X
TITLE ELIMINATION (Complete all but section 3, below)
TRANSFER IN LOCATION (Complete ALL sections below)
REMOVAL FROM REAL PROPERTY (Complete all but section 4, below)
wil MANUFACTURED HOME
TPO/PLATE NUMBER
56825
YEAR
1978
MAKE
SunyB
WIDTH/LENGTH
24/48
VEHICLE IDENTIFICATION NUMBER(VIN)
00305
Fa LAND
Attach legal description be from
a copy of the of your land. It can
Assessor's office or it may be typed or printed on an Additional
Manufactured home
obtained your Coun y
Attachment Form
REMOVED
PROPERTY TAX PARCEL NUMBER
55071.0503
will be
AFFIXED
TITLE COMPANY CERTIFICATION
I certify that the legal description of the land and ownership is true and correct per the real property records.
NAME
TITLE COMPANY/PHONE NUMBER
SIGNATURE
X
DATE
Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs.
KM BUILDING PERMIT OFFICE CERTIFICATION
I certify that the manufactured home has been affixed to the real property as described, or a building
permit has been issued for this purpose and the attachment will be inspected upon completion.
BLDG PERMIT N
il () 0 f 7
NAME
I�, 1
R-(L
SIG TUREITITL
BLDG PERMIT OFFICE/PHONE N
1CO,lq�4-3,71-
DATE
e-L/ ys-
X3( \+
/)A-41
OWNER INFORMATION
FEES
COUNTY # INC UNINC
irl
# REGISTERED OWNERS
1
N LEGAL OWNERS
1
Provide the Washington Driver's License or I.D.
card number (PIC) for each owner:
FILING FEE
y �•%� NAME OF FIRST OWNER
A .:.
Rebecca L. Osterlund
APPLICATION
I
_
G NAME OF SECOND OWNER
MOBILE HOME FEE$
..
_EE,: ADDRESS OF OWNER
18608 East Grace Avenue
--OR-- if the owner is a business,
ELIMINATION
)
0>� CITY
...
;YE,. t Otis Orchards
STATE
WA
ZIP CODE
99027
provide the Unified Business
Identifier (UBI), found on the
business Registration & Licenses
USE TAX
)_
NAME OF FIRST LEGAL OWNER'
..v
Document.
SUB-AGENT FEES
I
s.�ry MAILING ADDRESS OF FIRST LEGAL OWNER
H::
lienholder7 Please use attachment
TOTAL FEES & TAX
Oa CITY -
STATE
ZIP CODE
form(s) #TD-420-732.
$ )
EI
DEALER'S REPORT OF SALE
' 'SIGNATURE OF LEGAL OWNER INDICATES
ri,''- FROM REAL PROPERTY. X
CONSENT ELIMI ATION OF TRLE/REMOV
Y- UL10►� 11r u,(M(,j(
1 certify that this information is correct. The vehicle is clear
°f encumbrances except as shown.
Anyone who knowingly makes a false statement o1 a matenal fact is guilty o1 a felony. and
upon conviction may be punished by a fine of up to $5,000 and/or 10 years imprisonment
(RCW 46.12.210). I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY LAW
THAT 1/WE ARE THE REGISTERED OWNERS OF THIS VEHICLE AN THIS INFORMA-,,
TION I ACCURATE:(Owner Signeture(s) & Tllle(s):
X bP- C r' EIE Q _ ^ '
CC a ��1(/� L e p/y(`
WA DLR NO.
DATE OF SALE
PURCHASE PRICE
$
DEALER NAME
' .
TA%JURISOICTION/TAX RATE
DEALERS AUTHORIZED SIGNATURE
�—
X
USE TAX EXEMPT Sale to a Cedified Tribal member on
the reservation (attach notarized statement of delivery)
X _ _ N - r
NOTARY
OR LICENSE AGENT NUMBER
p
1 j 1 Q
: SU fOtSCRIBEtI TO AN SWyi�1iN B/E(F]OQFjE ME THIS
'1 /� I 19 /
Resi6 I Count
(Y
lLl k
lui
U O
COUNTY AUDIT°
AGENT L ENSING OFFICE APPROVAL: (Not use by Sub-Agents) VVV
r dPupeS ts)
I certify that the above application appears to have been coRipfeted correctly, and the applicant has sufficient documentation to
proceed with the recording of this form.
NAME
SIGNATURE
X
OFFICENFS OPERATOR NUMBER
DATE
TD -420-729 MANUF HOME APPL (R/1294)M Page 1 of 2