1996, 04-09 State MH License App i •
(Lai STATE Or W°'ASHINGTON
MANUFACTURED HOME
RECORDER'S CLOCK FILED AT THE REQUEST OF:
�IICEflSIflG
APPLICATION NAME
Please check one ADDRESS
TITLE ELIMINATION(Complete all but section 3,below)
TRANSFER IN LOCATION(Complete ALL sections below)
REMOVAL FROM REAL PROPERTY(Complete all but section 4,below)
0 MANUFACTURED HOME
TPO/PLATE NUMBER YEAR MAKE WIDTH/LENGTH VEHICLE IDENTIFICATION NUMBER(VIN)
Iyx�QIP
LAND
Attach a copy of the legal description of your land. It can be obtained from your County PROPERTY TAX PARCEL NUMBER
Assessor's office or it may be typed or printed on an Additional Attachment Form (TD-420-732).
Manufactured home will be AFFIXED REMOVED
TITLE COMPANY CERTIFICATION
I certify that the legal description of the land and ownership is true and correct per the real property records.
NAME TITLE COMPANY/PHONE NUMBER SIGNATURE DATE
X
Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs.
U BUILDING PERMIT OFFICE CERTIFICATION
I certify that the manufactured home has been affixed to the real property as described, or a building BLDG PERMIT k
permit has been issued for this purpose and the attachmentI jji inspected upon completion. I- Ilc
NA SIGNATURE/TITLE SPO{CANE "—' BLDG PERMIT OFFICE/PHONEU DATE
Cl i Z X ! DIVISION OP BUILDING AND PLANNING (5 oq)4 67o 3�75._ I9 - 1%
OWNER INFORMATION FEES
COUNTY U INC UNINC #REGISTERED OWNERS U LEGAL OWNERS Provide the Washington Driver's License or I.D. FILING FEE
II I I card number(PIC)for each owner:
NAME OF FIRST OWNER A APPLICATION
RE Lm,; -- Qø/Ji �
? NAME OF SECOND OWNER MOBILE HOME FEES
E ADDRESS OF OWNER ELIMINATION
R --OR--if the owner is a business,
provide the Unified Business
D• CITY STATE ZIP CODE USE TAX
Identifier(UBI),found on the
business Registration&Licenses
NAME OF FIRST LEGAL OWNER* Document. SUB-AGENT FEES
l
• MAILING ADDRESS OF FIRST LEGAL OWNER More than two owners or one TOTAL FEES&TAX
N lienholder? Please use attachment
OL CITY STATE ZIP CODE form(s) #TD-420-732.
DEALER'S REPORT OF SALE
R 'SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE/REMOVAL I certify that this information is correct. The vehicle is clear
FROM REAL PROPERTY: X of encumbrances except as shown.
Anyone who knowingly makes a false statement of a material fact is guilty of a felony,and WA DLR NO. DATE OF SALE PURCHASE PRICE
upon conviction may be punished by a fine of up to$5,000 and/or 10 years imprisonment
(RCW 46.12.210). I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY LAW DEALER NAME TAX JURISDICTION/TAX RATE
THAT I/WE ARE THE REGISTERED OWNERS OF THIS VEHICLE AND THIS INFORMA-
TION IS ACCURATE: Owner Signatures)&Title(s):
DEALERS AUTHORIZED SIGNATURE
X
USE TAX EXEMPT Sale to a Certified Tribal member on
X the reservation (attach notarized statement of delivery)
NOTARY OR LICENSE AGENT&NUMBER SUBSCRIBED TO AND SWORN BEFORE ME THIS Residing in(County)
X DAY OF 19
6 COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL:(Not for use by Sub-Agents)
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 SIGNATURE OFFICENFS OPERATOR NUMBER DATE
X
TD-420-729 MANUF HOME APPL(R/2/94)M Page 1 of 2