1996, 05-07 WA State MH Application Lh1STATE Of WASHINGTON RECORDER'S CLOCK
O-srteuat of lICEnSInG MANUFACTURED HOME APPLICATION
TITLE OPTIONS
Original 0 TITLE ELIMINATION (Complete all but section 3,below)
Transfer -- TRANSFER IN LOCATION (Complete ALL sections below)
Duplicate — REMOVAL FROM REAL PROPERTY (Complete all but section 4,below)
Reissue RECORDED AT
REQUEST OF:
1 ,_ MANUFACTURED HOME
YEAR MAKE WIDTH/LENGTH : ' :VEHICLE IDENTIFICATION NUMBER(VINI COLOR 81 .< COLOR 82
TOP ORBOTTOM OR
1986 Champion 44x24 1669545406 FRONT: IREARCOLOR:
2 LAND
• Attach a copy of the legal description of your land. It can be obtained from your Couaty Assessof s.office.
• Land to which the manufactured home is being:[ AFFIXED I I REMOVED PROPERTY TAX PARCEL NUMBER
55192. 1809
3 TITLE COMPANY CERTIFICATION
I certify that the legal description of the land and ownership are true and correct.
NAME ' ......' TITLE COMPANY/PHONE NUMBER.'
... ;:..SIGNATURE -' DATE
X
NOTE: Application must be finalized with a Licensing Agent within 10 calendar days of the date signed by the Title Company Representative.
4. BUILDING PERMIT OFFICE CERTIFICATION
I certify that the manufactured home has been affixed to the real property as described, or the BLDG PERMIT a
folio ing buildi g permit has been issued for this purpose and will be inspected upon completion. 87000607
N :-- �:' `. SIGNATURE/TITLE - :': `" :' - BLDG P T OFFICE/PHONE NUMBER DATETE /� �}
74t/u1j
� �, X SPKANCOLANNING15� (srf -;3/ I _OWNER INFORMATION 'FEE
5 COUNTY I ZINC UNINC NUMBER OF NUMBER OF pl Please provide the Department of Licensing (DOL) FILING FEE
I 1 [ REGISTERED OWNERS 1 LEGAL OWNERS 1 Client "NUMBER" for each owner: I
NAME OF FIRST REGISTERED OWNER _
N APPLICATION
E CINDI R. WARNER "Af1AIRIIJIICARil?Jj6l/+�11'I16
NAME OF SECOND REGISTERED OWNER I
.f MOBILE HOME FEES
1 I I I I I I I I I I
T ADDRESS OF FIRST REGISTERED OWNER This "NUMBER" may be found on 1
E
a 17315 East 6th Avenue your Washington Drivers License/ ELIMINATION
E` CITY STATE ZIPCODE I.D. Card--OR--if the owner is a
D, Greenacres WA 99016 business, provide the Unified
USE TAX
NAME OF FIRST LEGAL OWNER• business identifier(UBI)number.
Hege Company I I I I I I I l I I I (
I. MAILING ADDRESS OF FIRST LEGAL OWNER SUB-AGENT FEES
711 East Third Avenue More than two registered or
o I
A CITY STATE ZIPCODE one legal owner/ . . • TOTAL FEES &TAX
L Spokane WA 99202 Please use attachment forms
•SIONATURE OF LEGAL OW,y •DIL/A�E aONSEN FOR
'.,- a•" (TD-420-732)
ELIMINATION OF TITLE: t /fl IJS iF/ ( -. <-7--9 $ 1---
Anyone who knowingly make a false statement of a material fact is guilty `PURCHASE PRICE
DEALER'S REPORT OF SALE
of a felony,and upon conviction may be punished by a fine of up to 35,000
and/or 10 years imprisonment(RCW 46.12.2101.I DO SOLEMNLY ATTEST 'i illilffJ fff$i!llpgtgt;lslil�t (sption Is
UNDER PENALTY OF PERJURY LAW THAT I/WE ARE THE REGISTERED correct aye cre;�'Elka{!(lf ll!!I!llfli7 TAX JURISDICTION/TAX RATE
OWNERS OF THIS VEHICLE AND THIS INF RMATION IS ACCURATE: encumb i �� ep �hown. z.
Registered wrest S1 ture4sl: (Tule) p�T,�� p
X (� ,>...:.DEALEFt•Nna7Rt„FrU. �?L'�1t.UO .. •
,- DATE OF SALE
�4.-.� �� G�ir�.C.c.�, NOTARY PUBLIC STATE CF W-1--(-;G7C
_ COUNTY OF Sp N
X :F+d lk..}I` ERRE EssA )f t{ED SIIG NATURE
I
' 'fI;lith:/11 iifitllfitfitllil IIS„-? 7 ..:
X X P I:ii:f'
NOT '` T& Subscribed and Sworn to Before Me This Residing n
'•• �u �� RiSpokane .USE TAX EXEMPT Sala to Indian on the
/J
(,fes 3 YdDay of May 19 96 Spokane County Reservation(attach notarized statement of delivery)
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 - - - - OFFICE/!tl/E'Of/EI (TOR NUMBER DATE
X
7 RECORDING OFFICE
This form has been recorded in the t r ord
IVOLUME/PAGE DATE
TD-420-729 MANUF HOME APPL(R/7/e310R Page 1 of 2