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!Department of MOBILE HOME • <br /> Revenue` - REAL ESTATE EXCISE TAX AFFIDAVIT <br /> Washington State <br /> Submit to County Treasurer of the county Chapter 82.45 RCW This form Is your receipt when stamped <br /> in which property is located. Chapter 458-61A WAC by cashier <br /> FOR USE WHEN TRANSFERRING TITLE TO MOBILE HOME ONLY <br /> PLEASE TYPE OR PRINT <br /> INCOMPLETE AFFIDAVITS WILL NOT BE ACCEPTED <br /> Name Name <br /> 1 Michael Woldman,presumptively subject to the Ruth E Lennon <br /> community interest of his spouse if married on or since May <br /> 19,1995,date of acquiring said interest <br /> StreetStreet <br /> 10710 Holly Dr 10710 Holly Dr <br /> City State Zip Code z City State Zip Code <br /> Everett,WA 98204 Everett,WA 98204 <br /> Name Name <br /> Z QQJ W <br /> .Street U' Z Street <br /> 10710 Holly DrRuth E Lennon <br /> City State Zip Code City State Zip Code <br /> Everett,WA 98204 10710 Holly Dr <br /> PERSONAL PROPERTY REAL PROPERTY <br /> PARCEL or ACCOUNT NO. Everett,WA 98204 PARCEL or ACCOUNT NO. 005523-003-017-06 <br /> LIST ASSESSED VALUE(S):$ LIST ASSESSED VALUE(S):$ 1 <br /> MAKE YEAR MODEL SIZE SERIAL NO.or I.D. REVENUE TAX <br /> CODE N0. <br /> GRNHL 1986 48/28 0RFL2AF474805506 <br /> Date of Sale - AFFIDAVIT <br /> Taxable Sale Price $ 0.00 I certify under penalty of perjury under the laws of the State of <br /> Excise Tax: State $ Washington that the foregoing is true and correct. <br /> Snohomish Local $ Signature of <br /> Delinquent Interest: State $ Grantor/Agent <br /> Local $ Name(print) Chawalit Sprayberry <br /> Delinquent Penalty: $ Date&Place of Signing: <br /> Subtotal $ <br /> State Technology Fee ., $ 5.00 Signature of <br /> Affidavit Processing Fee $ 5.00 Grantee/Agent <br /> Total Due $ 10.00 Name(print) Ruth E Lennon <br /> If exemption claimed,WAC number&title: Date&Place of Signing: <br /> WAC No.(Sec/Sub) <br /> WAC Title <br /> A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX. <br /> TREASURER'S CERTIFICATE <br /> If,in selling(or otherwise transferring ownership of)a mobile home <br /> I hereby certify that property taxes due Snohomish County on the mobile which possesses a tax lien, the seller does not Inform the buyer <br /> home described hereon have been paid to and induding the year 2018. (new owner)of such a lien,the seller Is guilty of deliberate decep- <br /> tion as it applies to Fraud and/or Theft as defined In Title 9 and 9A <br /> (RCW 9.45.060,RCW 9A.56.010(4d),and RCW 9A.56.020). <br /> Date County Treasurer or Deputy <br /> THIS SPACE-TREASURER'S USE ONLY <br /> REV 84 0003e(6/26/14)COUNTY TREASURER <br />