2013, 07-15 Title EliminationRETURN RECORDED DOCUMENT TO:
Gustafson & Hogan, P.S.
1500 W. 4th Ave., Suite 408
Spokane, WA 99201
#13-00700
CILWASHINGTON STATE DEPARTMENT OF
LICENSING
Manufactured Home
Application
For full instructions on completing this form, see Manufactured Home Application
Instructions, form TD -420-730.
Please check one:
Title Elimination
❑Transfer in Location
❑ Removal from Real Property
1 Manufactured Home
TPO/Plate number
+168251
Year
1999
Make
Kit
Length/Width (feet)
63 x 27
Vehicle identification number (VIN)
KM1H9976SH244066
2
Land
Manufactured home will be
!9 Affixed • Removed
Real property
Tax no. 45072.0210 Legal description on page
parcel
Lot
4 & N 17' L5
Block
130
Plat name or Section/Township/Range
Orchard Avenue Addition
Quarter/Quarter section
3
Grantor(s) Registered/Legal Owner(s) — Additional names on page
County number
No. registered owners
1
No. legal owners
1
Grantee name (if applicable)
Name of registered owner
Louise Betz
Washington driver license or UBI number
Name of additional registered owner
Washington driver license or UBI number
Address (Address, City, State, ZIP code)
Name of legal owner
Numerica Credit Union
Washington driver license or UBI number
Name of additional legal owner
Washington driver license or UBI number
Address (Address, City State, ZIP code)
I decl-
owner)
I
- '- + • •
of this manufa
o
perjury under the laws of the state ashington that 1.. r e a : the registered
ured home and the foregoing inf tion is true nd-.rrect.�,
X % MP
4
�'
-
"'
Signa re of registered o ner an. -, if al).' able
X
4
11
o g
v o) O
Signature of additional registered owner and title, if applicable
State of� •County of 5w n trw
L N °
Q.mLn
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,
-�i(�I13
Signed or attested before me on
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4
,
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Pri red own me Print re t� owner name
J
a
a
Notary orinted or stamped name Notaryjg ur
ki tr.in and f �I1
4
Title Dealer/county office number or notary expiration
TD-420-729J4J12)WA Page 1 off 3
Continued on next page
factured home TPO/Plate number (from Section 1)
4 Title Company Certification
PRINT or TYPE 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
ce tify that
the manufactured home has been affixed
to the real property as described.
and the attachment will be inspected upon completion.
• a building permit has been issued for this purpose
PRINT o�T rE Tame o on si Hing _ -
ifvnh jam\ ipfL
Buil ing permit office
S[V/
Building permit number
a a /3sets
Position
EV • ceeie,i Naj k
(Area code) Telephone number
(,,/
X WIa Z 1 I I
Signature Date
• Signature of Legal Owner(s)
of Titl or Removal from real pro
!
signature
(
of legal owner indicates consent
Notary Public
State of Washington
YEVGENIYA A VOROPAY
My Appointment Expires Oct 28, 2014
r Elimination
/�`
` Signature of legal owner and e, if applble
X
Signature of additional legal owner and title, if applicable
rQS6) 141,14214, County of 5po(AR tot c
Notarization/Certification
(Seal
1
State of
Signed or attested before
or stamp) by
me on At frIL 1Q Jo ( B
,
ri uv+ksR4met C.0
by 7eM 7o '(..+G ttt e k
not registered owner name Print registeredwwner ryame
Print
V ; VI A Vo Riopcl Wit S2vf; !f c
Notary prinyed�or stamped name and Jp tary J gna�e g /o O/4
Title Dealer/countyooffice number or notary expiration
7 Land Description
Legal description of land
TD -420-729 (R/4/12)WA Page 2 of 3
Continued on next page
PO/Plate number (from Section 1
8 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
- Sale to a Certified Tribal member on the reservation (attach notarized statement of delivery).
• Sales Tax Exempt
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
9 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
10 Title Fees
Filing fee
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
TD -420-729 (R/4/12)WA Page 3 of 3
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