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L410 Etmm SHINGTON MANUFACTURED HOME
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APPLICATION El TITLE ELIMINATION
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Anyone who knowingly makes a false statement of a material fact is guilty REMOVAL FROM REAL PROPERTY
Dof a felony,and upon conviction may be punished by a fine,imprisonment,or both. (RCW 46.12.210)
MANUFACTURED HOME
TPO/PLATE NUMBER I YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN)
V21481 1968 I VANDK 50CT/20 5463
LAND
LEGAL DESCRIPTION ON PAGE 2
MANUFACTURED HOME WILL BE ®AFFIXED 0 REMOVED REAL PROPERTY TAX PARCEL NUMBER
936 600 020
LOT I BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE
20 QUARTER/QUARTER SECTION
BROOKWOOD GLEN
GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE
COUNTY NUMBER NUMBER OF REGISTERED OWNERS
I NUMBER OF LEGAL OWNERS
1 SAME AS REGISTERED OWNER
NAME OF REGISTERED OWNER
MAXINE WEST LIVING TRUST DOL CUSTOMER ACCOUNT NUMBER
NAME OF ADDITIONAL REGISTERED OWNER
DOL CUSTOMER ACCOUNT NUMBER
MAXINE WEST,TRUSTEE
ADDRESS CITY
10 GLEN AVE STATE ZIP CODE
CHIMACUM WA 98325
NAME OF LEGAL OWNER
DOL CUSTOMER ACCOUNT NUMBER
NAME OF ADDITIONAL LEGAL OWNER
DOL CUSTOMER ACCOUNT NUMBER
ADDRESS CITY
STATE ZIP CODE
GRANTEE
NAME
I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AWARE 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
by MAXINE WEST,TRUSTEE Signature
PRINTED NAME OF REGISTERED OWNER NOTARY OR AGENT
by
PRINTED NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY
Title County/Office No.OR
AND: Dealer
DEALERSHIP POSITION/AGENT/NOTARY
Notary Expiration OR
Date
TITLE COMPANY CERTIFICATION
I certify that the legal description of the land and ownership is true and correct per the real property records.
NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER
Jefferson Title Company (360)385-2000
SIGNATURE/POSITION
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: 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
NAIyIF(TYPED PRINTFD) BLDG PERMIT OFFICE/PHONE# BLDG PE IT#
IGNATURE/P k 1— 4- C) �C ,
DATE
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