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2009, 07-27 Title EliminationRETURN ADDRESS OF WASHINGTON MANUFACTURED HOME PLEASE CHECK ONE LlSLAP- Department of icEnsinc APPLICATION ii TITLE ELIMINATION ■TRANSFER IN LOCATION 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 III REMOVAL FROM REAL PROPERTY both. (RCW 46.12.210) D MANUFACTURED HOME TPO / PLATE NUMBER YEAR 1 9 MAKE CALps LENGTH/WIDTH(FEET) S-2 X A.,-( VEHICLE IDENTIFICATION NUMBER (VIN) GW/d/o REcA 7V..t.-1-. 2 LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE [AFFIXED • REMOVED REAL PROPERTY TAX PARCEL NUMBER LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 3 GRANTOR(S) REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS / NUMBER OF LEGAL OWNERS / NAME/{jam /�\JOF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE b`%/ /V, /4c/y ,s rce,J fl --c- -.c S 4/4 ..! 7o/' NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER S,4i4..c_ 4-s 4,64=1/ -42 NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 542-nt ‹ 4-5 %1--.br/✓, GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT 1 / WE AM/ARE THE REGISTERED OWNER(S) OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE Signature of Additional Registered Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S) SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No. OR Title AND: Dealer No. OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME (TYPED OR PRINTED) TITLE COMPANY / PHONE NUMBER SIGNATURE / POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. © BUILDING PERMIT OFFICE CERTIFICATION I certify that: 0 the manufactured home has been affixed to the real property as described. la building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME ( YPED OR PRINTED) c43 V Yr:A. BLDG PERMIT OFFICE/PHONE # t r v0g -1056-026 3 BLDG PERMIT # S-3io02L iSt NATO / POSIT -�-N�/'/ry DATEE Q 7,2,3 1Zt..,.. , 4.,/citv-,,,--i- 41/E9 2/02)OR (W)Page 1 of 2 MANUFACTURED HOME - FROM SECTION 1 TPO/ PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) X VEHICLE IDENTIFICATION NUMBER (VIN) 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR E TION OF TI L / REMO L FROM REAL PROPERTY. Signature of Legal Owner and Title, IF APPLICABLE Signature of Additional Legal Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S) SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF LEGAL OWNER NOTARY OR AGENT by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY County/Office No. OR Title AND: Dealer No. OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date El LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) 8 DEALER'S REPORT OF SALE 1 CERTIFY THAT THIS INFORMATION IS CORRECT. THE VEHICLE IS CLEAR OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REQUIRED SALES TAX HAS BEEN COLLECTED. DEALER NAME (TYPED OR PRINTED) WA DEALER NUMBER DATE OF SALE PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALER'S AUTHORIZED SIGNATURE • USE TAX EXEMPT Sale to a Certified Tribal member on the reservation (attach notarized statement of delivery). 9 COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL: (Not for use by Subagents) I certify that the above application appears to have been completed correctly, and the applicant has sufficient documentation to proceed with the recording of this form. NAME (TYPED OR PRINTED) COUNTY OFFICENFS OPERATOR NUMBER SIGNATURE DATE 10 TITLE FEES FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES IMPORTANT: Once the application has been approved by the County Auditor / Vehicle TOTAL FEES & TAX Licensing Office, take your application form to the County Recording Office. Retain proof of the recording fees paid. If the Recording Office retains your original application form, obtain a certified copy of the recorded form. APPLICANTS: Once recorded, you must return to a Vehicle Licensing office to file the Manufactured Home Application, paying all required fees. Vehicle licensing subagents charge a service fee. For full instructions on completing this form for Title Elimination, Removal from Real Property or Transfer in Location, see form TD -420-730, Manufactured Home Application Instructions. The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation, please cal (360) 902-3600 or TTY (360) 664-8885. TD -420-729 MANUF HOME APPL (R/2/02)OR (W )Page 2 of 2