2007, 04-19 Title EliminationJ
RETURN ADDRESS
GUSTAFSON & HOGAN, P.S.
2829 S. GRAND BLVD., STE. 302
SPOKANE, WA 99203
J WASHINGTON STATE DEPARTMENT OF Manufactured Home ®TITLE ELIMINATION
(I• L I C E N S I N G Application ❑TRANSFER :N LOCATION
❑REMOVAL FROM REAL PROPERTY
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 46.12.210)
MANUFACTURED HOME
TP0 / PLATE NUMBER
YEAR
a�6
MAKE drI«f)I
C6u',a,t
LENGTH/WIDTH(FEET)
box 1a7
VEHICLE IDENTIFICATION NUMBER (VIN)
V M 11 � ZO w O $'!�
LAND IF 0'7'7 IT LEGAL DESCRIPTION ON PAGE
REALP OPERTYT�;PA?CILDNU_pQPER
MANUFACTURED HOME WILL BE AFFIXED ❑REMOVED � 3 a`JL•
LOT
BLOCK
PLAT NAME OR SECTION/TOWNSHIP/RANGE
QUARTER/QUARTER SECTION
GRANTOR(S) REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE
COUNTY NUMBER
NUMBER OF REGISTERED OWNERS
NUMBER OF LEGAL OWNERS
NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER
NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER
-- �.....
`
7 —` 1,
ADDRESS CITY STATE ZIP CODE
NAME OF LEGAL OWNER DOL cusr6MER ACCOUNT NUMBER
NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER
ADDRESS CITY STATE ZIP CODE
GRANTEE
NAME
I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I / M/ E E RE STER WNER(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
P
NOTARY SEAL OR STAMPNOTARIZATION/CERTIFICA ION FOR REGI ERED OWNE )SIGNATURE
State of Washington C Signed or attested
County of V�oKtx n before me on
y uf'in n , C't�� iu Signatur
PRINT NAME OF REGISTER DWNERI N ARY OR G NT
AIGE WILLINGNAM I y QL
/tTE OF WASHINGTON ( �o ��-if �1 l7Oh •
PUBLIC I y PRINT NAME OF REGISTERED OWNER PRINTED AM"F NOTARY
QTARY
A t r, County/Office No. OR
EXPIRES I , oia _ AND: Dealer No. OR
v
COMMISSION ,itle
DEALERSHIP POSITIONA"ENT/NOTARY Notary Expiration Date
jjTI TION
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
DATE
SIGNATURE / POSITION
Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs.
BUILDING PERMIT OFFICE CERTIFICATION
El the manufactured home has been affixed to the real property as described.
I Certify that:
® a building permit has been issued for this purpose and the attachment will be inspected upon completion.
NAME (TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE s
BLDG PER 4
,...�G
DATE
'S11 NA RE / P I ION
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