1995, 09-21 State of WA MH App 161$01g //rLI Avg
El(lrp5T=a7rfinE Orrnt WAofSHI ETON RECORDER'S CLOCK
lIcEnsInG MANUFACTURED HOME APPLICATION
TITLE OPTIONS
r---_, Original n 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 I:- r WIDTH/43140TH i:! >VEHICLE IDENTIFICATION'NUMBER:MN) > <' COLOR: 411 - COLOR#2
//��� ��� ^�/�D TOP OR BOTTOM OR
l/A CJ( / FRONT: I REAR COLOR:
2 LAND
• Attach a copy of the legal description of your land. It can be obtained from your Couty Assessor's� office.
• Land to which the manufactured home is being:J AFFIXED REMOVED PR477 / jj 5
3 ^ TITLE COMPANY CERTIFICATION 1 7 -7
I certify that the legal description of the land and ownership are true and correct.
NAME TITI.E 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.
1 4 BUILDING PERMIT OFFICE CERTIFICATION
JI certi that the manufactured home has been affixed to the real property as described, or the amp P61MIT,
folio in buildings it has been issued for this purpose and will be inspected upon completion. t /r /�o
NAM { i 'SIGNATURE/TITLE> .:: BLDG PERMIT.0 CE/PHONE NUMBER AT
��%jL 'Ld\// ( t/ X SPOKANE COUNTY
DIVISION OF BUILDING AND PLANNING -5�•/ /-� // Zi/CA-;
�% OWNER INFORMATION 'FEES
5 COUNTY INC LINING NUMBER OF NUMBER OF Please provide the Department of Licensing (DOL) FILING FEE
L I n REGISTERED OWNERS LEGAL OWNERS Client"NUMBER"for each owner:
I t I
NAME OF FIRST EGISTERED OWNER APPLICATION
FOX , Hou riD Fa 1 +R1R1 i ?i 1t
r NAME OF SECOND REGISTERED OWNER
y� L
FOX YIRG1/)�A ! / Ol�1 Vl�i51G16-5
MOBILE HOME FEES
ADDRESS OF FIRST REGISTERED OWNER This "NUMBER" may be found on
ia�r5 E d''7-T}-f u3-//N�a your Washington Drivers License/ ELIMINATION
CITY STATE ZIPCODE I.D.Card--OR--if the owner is a
��� 9t1 Iv business,provide the Unified �—
NAME OF FIRST LEGAL OWNER• -
business identifier(UBI)number. USE TAX
.P Cpay ner6A6o 1 1 l 1 1 1 i 1 I 1 1 1---
LL MAI G PRESS OF FI6$j.,l•E,�A�_OWNER SUB-AGENT FEES 1
E (• rJ /�//J�L�7f�[ c•/{UXP�G)y More than two registered or
A CITY ^ STATE z c DE one legal owner? . . .
L V\LGaQd Ill TLE
Oh Please use attachment forms TOTAL FEES &TAX
•SIGNATURE OF LEGAL�ggWW*(ER INDICATES CONSENT FOR I DATE (TD-420-732)
'ELIMINATION OF TITLE: l
Anyone who knowingly makes a false statement of a material fact is guilty DEALER'S REPORT OF SALE PURCHASE PRICE
of a felony,and upon conviction may be punished by a fine of up to$5,000 $
and/or 10 years imprisonment(RCW 46.12.2101.I DO SOLEMNLY ATTEST I certi •.t this information is
UNDER PENALTY OF PERJURY LAW THAT I/WE ARE THE REGISTEREDcorrect. The • ole is clear of TAX JURISDICTION/TAX
OWNERS OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: encumbrances excep shown.
Registered Owner signaturefsl: (Title)
, -..X DEALER NAME. D
/' X
WA[ARNO 'i D •'S`AUTHORIZED iSIGNATURE '
X X
/,jOTARY OR UCENSE AGENT&NUMBER Subscribed and Sworn to Before Me This Residing in ,
USE TAX EXEMPT Sale to Indian on ^
Day of 19 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 .. OFFICENFS OPERATOR NUMBER DATE
X
7 RECORDING OFFICE
This form has been recorded in the county records.
RECORDING NUMBER .. .. .. COUNTYI. VOLUME/PAGE `DATE
TO-420-729 MANUF HOME APPLIR/7/931OR Page 1 of 2