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2010, 02-01 Permit 09001881 Title EliminationRETURN ADDRESS fZfg:fA 140 VAN Manufactured Home rr WASRIR6IRN DEPARTMENT OF dTITLE ELIMINATION aR LICENSING Application ❑TRANSFER IN LOCATION ❑REMOVAL FROM REAL PROPERTY 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 40.12.210) MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTWWIDTN(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) y\ C AU X /� _ 00 f LAND LEGAL DESCRIPTION ON PAGE RF,Ay.. �; P,g3 TAx,P,(�R_gFiryuntBER MANUFACTURED HOME WILL BE ® AFFIXED ❑ REMOVED �`II `J Y LOT BL!]CL(� � PLAT NA EOR SE OWTOWNSHIPM1iANGE OUA�RTE IR/OUARTEA SECTION Er GRANTOR(S) REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LLi;A1 OWNERS I , NAMrn 07 DOWN DOL CUSTOMER ACCOUNT NUMBER 11 NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTORAER ACCOUNT NUMBER fTV ADDRESS CSTATE ZIP CODE 3�9j Al llck- Ad NAME OF LEGAL " R DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL LEGAL OW ER DOL CUSTOMER ACCOUNT NUMBER ADDRESSN C / / STATE ZIP ODE D.c�% d /4 GRANTEE NAME 1 DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT 1 / WE AM/ARE THE REGISTERED OWNER(S) OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE Signature of Additional Registered Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S) SIGNATURE State of Washington Signed or attested County of before me on bySignature PRI NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTIDNAMEOFNOTARY County/Office No. OR Title AND: Dealer No. OR DEALERSHIP POSfTIOWAGENTINOTARY Notary Expirabon Date TITLE COMPANY CERTIFICATION I certHy that the legal description of the land and ownership is true and correct per the rgal property records. NAME(TYPED OR PRINTED) DILE COMPANY/PHONE NUMBER SIGNATURE / POSmON DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. BUILDING PERMIT OFFICE CERTIFICATION I Certify that: It the manufactured home has been affixed to the real property as described. 0 a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME (TYP DOR PRINTED).. � A / BLDG PERMIT O� C � nl... 1116 PERMIT A �G .. DATED SIGNAIU E /POSmON , -: .� c^ 10 IIYAZa42FI lwlvnBl W Page 10 2 MANUFACTURED HOME - FROM SECTION 1 TPO/PIATENUMBER YEARMAKE LENGTWVADTH(FEE) VEHICLE IDEMIFICATION NUMBER(VINT I SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE / REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Tltle, IF APPLICABI F- / va.a/ss� ( .� %��,�I / Signature of Additional Legal Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S) SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF LOWNER NOTARY OR AGENT by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY County/OINoe No. OR Title AND: Dealer No. OR DEALERSHIP POSITIOWAGENT/NOTARY Notary Expiration Dale LAND DESCRIPTION (A legal description of ma land can be obtained from the local County Aesessoes Office) T R 6 o F SP 9S /Da7 Qud f01sF IV gsiv�vai(o /C:4 P6 .S'/ BP.izy 9 Aril/ or= ,c r / .lx A/9 DF ,Y1f eX117y-1-eNS -146 IlUl-Ch • DEALER'S REPORT OF SALE 1 CERTIFY THAT THIS INFORMATION IS CORRECT. THE VEHICLE IS CLEAR OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REOUIRED SALES TAX HAS BEEN COLLECTED. DEfl NAIAE(TYPED OR PRINTED) WA DEALER NUMBER 1 DATE OFISALE S q1i� PURCHASE PRICE TAXJURISDICTKWTAX RATE 5°0 D AUTHORIZED TUR 832pocia3 USE TAX EXEMPT Sale to a Certified Tribal meriliberon thef reservation (attach notarized statement of delivery). !3 COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL: (Not for use by Subagents) 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 (TYPED Oft PRINTED) COUNTY OFFICENFS OPERATOR NUMBER SIGNATURE 1 GATE i-' 1 TITLE FEES FLUNG FEE APPLICATION MO&LE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES TOTALFEESBTAX IMPORTANT: Once the application has been approved by the County Auditor/ Vehicle Licensing Office, take your application forth to the County Recording Office. Retain proof of the recording fees paid. If the Recording Office retains your original application form, obtain a certified copy of the recorded form. APPLICANTS: Once recorded, you must return to a Vehicle Licensing office to file the Manufactured Home Application, paying all required fees. Vehicle licensing subagents charge a service fee. For full instructions on completing this forth for Title Elimination, Removal from Real Property or Transfer in Location, see form TD-420-730, Manufactured Home Application Instructions. The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation, please cal (360) 902-3600 or TTY (360) 664-6885. TD 420 729 (WOM) W Page 2 of 2 `�• �`� '��y�[ 1. 9('905 MO©iJL[NE �x3IN I'lp ✓•� F D:.vx ul Gha.mn. ai *last Uoitdr� Co )ATE: 08/14/09 INVOICE NO.: 017-006033 iERIAL NO.: 017-OOP-H-006033AB YEAR:2010 BRAND NAME: Moduline VIP 4O. WHEELS: 16 NO. AXLES: 8 SHIPPING WEIGHT:44,740 iERIES OR MODEL HMV654 BASE DESCRIPTION 30'4' x 44' 3BR 2BA )ATE OF MANUFACTURE: 08/13/09 WIDTH: 30'4" LENGTH: 44'0" The undersigned Manufacturer hereby certifies that the new manufactured home described herein, the property of the manufacturer, has been transferred on the date set forth herein, subject to the terms and conditions of the invoice or other applicable agreement with the designated Distributor/Dealer. Greenfield III Corp Greenfield Homes P.O. Box 9 Colbert, WA 99005 The manufacturer certifies that a good and marketable title is being transferred and that no other valid manufacturer's certificate of origin is issued and outstanding on the. manufactured home described herein. 425 Sunnyside Ro ' in P.O, Box19b .