2005, 12-14 Title EliminationRETURN ADDRESS
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TD -420-729 MANUF HOME APPL (R/2/02)OR (W)Page 10
MANUFACTURED HOME
L/7S7A'I'h: OF WASh41NGTON
brpu [mmt of
IICEIIS1flG APPLICATION
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
��'���Fyxy"Ixy'�el'f�1
®TITLE ELIMINATION
TRANSFER IN ilk REMOVAL FROM REAL PROPERTY
both. (RCW 46.12.210)
1
MANUFACTURED HOME
TP
CIO
/ PLATE NUMBER
Li (5 „' g
YEAR'S �a
+992
MAKE
Champion
LENGTH/WIDTH(FEET)
24 X 64
VEHICLE IDENTIFICATION UMBER (VIN)
Serial S-41
4EGAL DESCRIPTION ON PAGE
2
LAND
MANUFACTURED
HOME WILL BE
l _.'
AFFIXED
II
REMOVED
REAL PROPERTY TAX PARCEL NUMBER
55071.0506
LOT
6
BLOCK
3
PLAT NAME OR SECTION/TOWNSHIP/RANGE
Riverview Mobile Home Subdivision
QUARTER/QUARTER SECTION
ADDITIONAL NAMES ON PAGE
3
GRANTOR(S) REGISTERED/LEGAL OWNER(S)
COUNTY
NUMBER
NUMBER OF REGISTERED OWNERS
2
NUMBER OF LEGAL OWNERS
2
NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER
Craig Jackson
NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER
Jennifer J. Jackson
ADDRESS CITY STATE ZIP CODE
2824 North Rivista Drive Otis Orchards WA 99027
NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER
Craig Jackson
NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER
Jennifer J. Jackson
ADDRESS CITY STATE ZIP CODE
2824 North Rivista Drive Otis Orchards WA 99027
GRANTEE
NAME
Same as registered owner
I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I / WE AM/ARE HE REGISTERED OWNER(S) OF THIS
VEHICLE AND THIS INFORMATION IS ACCURATE:
APPLICABLE T - =- -
Signature of Registered Owner and Title, IF
Owner Title, IF APPLICABLE
_
'h— -'t'L.
and
Signature Oild�ki,,,���4t,,,�,,,?���n___4'''
///R���egistered
NALOGSEALO Lv�fYe 1 NOTARIZATION/CERTIFIC {ON FOR REGISTE D OWNER(S) SIGNATURE
N..� S '•..•• CO TO ''� Signed or attested
ilk May . y.,I State of Washington 0 C,t �L< c_
d' 0C) k_ before me on ' 75 - CY`I
1r;' ,` County of .)
=o•.< ¢ s i tl ('��,
��'S �, s 'a4 V Rk < J etc Jt,11 Signature. - 'II Idl1C./1 �;1�''NL41
byQ
>�' '� ' * • y PRINT NAME F REGISTERED OWNER - NOT RY OR AGENT
byc ] �.Y11 A 4 r , cC ,,,, , ,--„ , � 1.e ►. t
.py/ �' �' I ) < C 1�a `C,I� �i 1
•..... ••".
*TION*TIO//�IIIIr�1N��, ```� I PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY 4
County/Office No. OR
NI Litkl t AND: Dealer No. OR `> 11 1' (T
Title
DEALERSHIP POSITION NT/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.
5
BUILDING PERMIT OFFICE CERTIFICATION
I certify that: itthe manufactured home has been affixed to the real property as described.
IIIM a building permit has been issued for this purpose and the attachment will be inspected upon completion.
AME (TYPED OR PRINTED) i BLDG PERMIT OFFICE/PHONE # GI4 (- ( (�j 00
-., .-, 2 I
BLDG PERMIT #
OS -1�)5
9
/SFS ATURE / SITION
` DATE I
A_A
I
TD -420-729 MANUF HOME APPL (R/2/02)OR (W)Page 10