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2011, 08-05 MH App for Title Elimination RETURN ADDRESS L1°,�;fit;SHlNGTON MANUFACTURED HOME PLEASE CHECK ONE licEnsinG APPLICATION TITLE ELIMINATION ❑TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty ❑REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine,imprisonment,or both.(RCW 46.12.210) III MANUFACTURED HOME TPO/PLATE NUMBER YAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) ..........rOO a 7-1 iX //k, P#d?( 9 9 LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE ❑ AFFIXED ❑ REMOVED LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 9 GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS NAME OF REGISTRED OWNER DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATEIP CODE 10\5 a Ru-kr Ne 3p ►o wPt- �Z tZ NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRE7D? +V SI4��e Zd ( CITYSTATEv V STATE CODE GRANTEE /�'A�l q2 2t1\Z NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE A rhe* ...&-4-i_ai 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 r" County of 0A, before me on �ly� by &Z /- 4i�I-1_ Signature 1_ / /40: /& PRINT NAME OF REGISTERED OWNER NO •'A EN- by /I��� r.IX/'j' PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR,o-) �� Title AND: Dealer No.OR(9, C/, L?:0 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: plthe manufactured home has been affixed to the real property as described. ❑ a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAE(T/Y�PEE�D�Ot OR PR TED) 1 1 y BLDG PERMIT OFFICCE7/P^�HONNE�# j��/ BLDG( P-EERMMIT# 7 005 SIGNA VIE/POSITION 9 'n^l j c:i ‘0-4-- -4-- zDiTTE/I i • TD-42.- 9 MANUF HOME APPL Z7Q1 )OR(W)Page 1 of 2