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1995, 11-28 State MH Application 4STATE OF WASHINGTON MANUFACTURED HOME RECORDERS CLOCK FILED AT THE REQUEST OF: ° °`rm` °' lICEnSInG 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) ® MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE WIDTH/LENGTH VEHICLE IDENTIFICATION NUMBER(VIN) 89 CHMPN 28/52 %114445 © 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). 45204.1653 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. 4 BUILDING PERMIT OFFICE CERTIFICATION I ce ' hat the manufactured home has been affixed to the real property as described, or a building BLDG PERMIT# per it has bee�yl ued for this purpose and the attachment will be inspected upon completion. 455th t ' NA E I/ / SIGNATURE/TITLE BLDG PERMIT FFICE/PHONE If DATE J�/ es JJ X SPOKANE COUNTY !� /l- rte/ r %//r 'C U� DIVISION OF BUIID(NG ANn PLANNIN( 1. � �� �, ��/ / OWNER INFORMATION FEES COUNTY# INC UNINC #REGISTERED OWNERS #LEGAL OWNERS Provide the Washington Drivers License or I.D. FILING FEE I I I 3 1 card number(PIC)for each owner: NAME OF FIRST OWNER APPLICATION R E MAXINE M. PINSON G NAME OF SECOND OWNER MOBILE HOME FEES I T LOUIS J. YUSE and LOURANE E. YUSE E ADDRESS OF OWNER ELIMINATION e 1010 S. Walnut --OR--if the owner is a business, D CITY STATE ZIP CODE provide the Unified Business USE TAX Identifier(UBI),found on the Spokane Wa' 99206 business Registration&Licenses NAME OF FIRST LEGAL OWNER' Document. SUB-AGENT FEES SPOKANE RAILWAY CREDIT UNION E MAILING ADDRESS OF FIRST LEGAL OWNERMore than two owners or one TOTAL FEES&TAX N Hlienholder? Please use attachment 0 301 N. Havana Street L CITY STATE ZIP CODE form(s) #TD-420-732. $ D • /Spokane WA 99202 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 SIgnature(s)&TItle(s): DEALERS AUTHORIZED SIGNATURE x X invm. yt ate 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 28 DAY OF November 19 95 Spokane 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 tc proceed with the recording of this form. NAME • SIGNATURE OFFICENFS OPERATOR NUMBER DATE X TD-420-729 MANUF HOME APPL(R/12/94)M Page 1 of 2