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2012, 04-16 WA State MH Application t R RETURN RECORDED DOCUMENT TO: Ford Law Offices 320 S. Sullivan Rd. Spokane Valley, WA 99037 diWASHINGTON STATE DEPARTMENT OF Manufactured Home Please check one: . LICENSING Application ETitle Elimination For full instructions on completing this form,see Manufactured Home Application ❑Transfer in Location Instructions,form TD-420-730. ❑Removal from Real Property 0 Manufactured Home TPO/Plate number Year Make Length/Width(feet) Vehicle identification number(VIN) 446309 2007 Skyline 44 X 28 2F910327V B Land Manufactured home will be Real property ❑✓ Affixed ❑Removed Tax parcel no. 55192.1918 Legal description on page Lot Block Plat name or Section/Township/Range Quarter/Quarter section 18 4 Apple Valley Estates Second Addition © Grantor(s) Registered/Legal Owner(s)—Additional names on page County number No.registered owners No.legal owners Grantee name(if applicable) 1 1 Name of registered owner Washington driver license or UBI number Florence F. LaValley LAVALFF512KR Name of additional registered owner Washington driver license or UBI number Address(Address,City,State,ZIP code) 17410 E. 6th Ave., Spokane Valley, WA 99016 Name of legal owner Washington driver license or UBI number Same as registered owner Name of additional legal owner Washington driver license or UBI number Address(Address,City State,ZIP code) I declare under penalty of perjury under the laws of the state of Washington that I am/we are the registered owner(s)of this manufactured home and the foregoing information is true and correct. a/4 Signature of registered owner and title,if applicable STEPHEN H. FOND 's �( STATE or WAS(:IN ;Ti ; F Signature of additional registered owner and title,if applicable otarif9tr IA r irtt9n3 L i . tate of /''-eit ,County of Ark MY COMMISSION EXPir;ES igned or aflested before me on 00/2 ( eal or stampP`t 22-12y r(,te^c' L. .iter by -------- --_._.- ------..-.. Print registered owner name Print registered owner name Str401 .*eie1 X /. - moi Notary printed or stamped name .ary signature f and V.,,,/,.,_Title / Dealer/county office number or notary expiration TD-420-729(R/4/12)WA Page 1 of 3 Continued on next page Manufactured home TPO/Plate number(from Section 1) Q Title Company Certification PRINT or TYPE Name of person signing Title company name Position (Area code)Telephone number I certify that the legal description of the land and ownership is true and correct according to the real property records. X Signature Date © Building Permit Office Certification I certify that ❑✓ the 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. PRINT orTYPE Name of person signing Building permit office Building permit number (-k / vre,1 7� .3paILA►xe ���►1eI MN-06003515- Position / /// / (Area code)Tele phone number 7l��� fel 4.1/T C e+o�I T CIS 1 09- /70-5 %V S' na re Date QSignature of Legal Owner(s) Signature of legal owner indicates consent for Elimination of Title or Removal from real pro erty. Mr. Sign ure of legal owner and title,if applicable ni(._ o ti°r Si'ili( I X drOTARY i _ tB- Signature of additional legal owner and title,if applicable UiC N���f �� R:TPii 21.: State of "� ,County of r`11 < 09-22-12 Signed or attested before me on Y fir—- hx (Seal or stamp) by I�y�'O^" L, (4,1_1(4/ by y Print registered owner name / Print registered owner name Notary printed or stamped name ry signature and /e�' Title / Dealectetsrityoffice number or notary expiration 0 Land Description Legal description of land Lot 18, Block 4, Apple Valley Estates Second Addition, as per plat recorded in Volume 12 of Plats, Page 31; Situate in the County of Spokane, State of Washington. TD-420-729(R/4/12)WA Page 2 of 3 Continued on next page l Manufactured home TPO/Plate number(from Section 1) QDealer Report of Sale—Selling dealer complete this section PRINT or TYPE Dealer name Washington dealer number Date of sale Purchase price Tax jurisdiction/Tax rate ❑Sales Tax Exempt—Sale to a Certified Tribal member on the reservation (attach notarized statement of delivery). I certify that this information is correct.The manufactured home is clear of encumbrances except as shown. Any required sales tax has been collected. X Dealer authorized signature 0 County Auditor/Agent Licensing Office Approval (not for use by subagents) PRINT or TYPE Name County office/VFS operator number I certify that the above application appears to be completed correctly, and the applicant has sufficient documentation to proceed with the recording of this form. X Signature Date 10 Title Fees Filing fee Application Mobile home fee Elimination fee Use tax Subagent fees Total fees and tax 0.00 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 both. RCW 46.12.750 We are committed to providing equal access to our services. TD-420-729(R/4/12)WA Page 3 of 3 If you need accommodation,please call(360)902-3600 or TTY(360)664-0116.