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2012, 02-29 WA State MH Application 4:2') RETURN RECORDED DOCUMENT TO: • 1 C'TY s3- JpOKANIF VALLEY et• • WASHINGTON STATE DEPARTMENT OF Manufactured Home PLEASE CHECK ONE dL LICENSING Application VITitle Elimination ❑Transfer in Location For full instructions on completing this form, see Manufactured Home Application ❑Removal from Real Property Instructions,form TD-420-730. 0 Manufactured Home TPO/Plate number Year Make Length/Width(feet) Vehicle identification number(VIN) Id73776 /yg,5"- kir _9 X -.5Y, c7C P Vi 4//qI 3 Land Manufactured home will be Real property ®Affixed El Removed Tax parcel no.3' Z'/ L _ fi 51-/K Legal description on page Lot Block Plat name or Section/Township/Range Quarter/Quarter section © Grantor(s) Registered/Legal Owner(s)—Additional names on page County number No.registered owners No.legal owners Grantee name(if applicable) Name of registered owner WA Driver license or UBI number Name of additional registered owner WA Driver license or UBI number Address(Address,City,State,ZIP code) Name of legal owner WA Driver license or UBI number Name of additional legal owner WA 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. X Signature of registered owner and title,if applicable • X Signature of additional registered owner and title,if applicable Notarization/Certification State of ,County of Signed or attested before me on (Seal or stamp) by by Print registered owner name Print registered owner name X Notary printed or stamped name Notary signature and Title Dealer/county office number or notary expiration TD-420-729(Ri6/11)W Page 1 of 3 Continued on next page Manufactured home TPO/Plate number(from Section 1) 4 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 VI c� ify 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 or TYP Name of personsigningBuilding permit office/ Building`permit number M iVN3/-V(. l CSV 00- 120001S-8 Position (Area code)Telephone number S&J(O . PeR�i(r Sp€. ,&iS meq. 7 21) . s3 / X /14:-YAA4_„,_ 2 /1Z Signature Date 6 Signature of Legal Owner(s) Signature of legal owner indicates consent for Elimination of Title or Removal from real property. X Signature of legal owner and title,if applicable X Signature of additional legal owner and title,if applicable Notarization/Certification State of , County of Signed or attested before me on (Seal or stamp) by by Print legal owner name Print legal owner name P� Notary printed or stamped name Notary signature and Title Dealer/county office number or notary expiration El Land Description Legal description of land TD-420-729(FV6/1t)W Page 2 of 3 Continued on next page • • Manufactured home TPO/Plate number(from Section 1) aDealer Report of Sale—Selling dealer complete this section PRINT or TYPE Dealer name WA 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 g 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&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/6111)W Page 3 of 3 If you need accommodation,please call(360)902-3600 or TTY(360)664-0116.