Mobile Home Real Estate Excise Tax Affidavit
MOBILE HOME
REAL ESTATE EXCISE TAX AFFIDAVIT
Submit to County Treasurer of the
county in which property is located.
Chapter 82.45 RCW
Chapter 458-61A WAC
Reset This Form
This form is your receipt when
stamped by cashier.
FOR USE WHEN TRANSFERRING TITLE TO MOBILE HOME ONLY
PLEASE TYPE OR PRINT
INCOMPLETE AFFIDAVITS WILL NOT BE ACCEPTED
Street
City
State
Zip code
Phone number
Name
Street
City
State
Zip code
NEW REGISTERED
OWNER (Buyer)
Name
LEGAL OWNER
LOCATION OF
MOBILE HOME
REGISTERED
OWNER (Seller)
Name
Street
City
City
LIST ASSESSED VALUE(S): $
MODEL
SIZE
Taxable Sale Price ............................................ $
Excise Tax:
State........................................... $
0.00
Local..........................................$
0.00
Delinquent Interest: State ............................... $
0.00
Local ..............................$
Subtotal ............................................................ $
0.00
0.00
0.00
State Technology Fee ....................................... $
5.00
Affidavit Processing Fee................................... $
5.00
Total Due .......................................................... $
10.00
Select Location
Delinquent Penalty ........................................... $
If exemption claimed, WAC number & title:
WAC No. (Sec/Sub)
WAC Title
Zip code
Street
LIST ASSESSED VALUE(S): $
Date of Sale
State
Name
REAL PROPERTY
PARCEL or ACCOUNT NO.
YEAR
Zip code
Phone number
PERSONAL PROPERTY
PARCEL or ACCOUNT NO.
MAKE
State
SERIAL NO. or I.D.
REVENUE TAX
CODE NO.
AFFIDAVIT
I certify under penalty of perjury under the laws of the State of
Washington that the foregoing is true and correct.
Signature of
Seller/Agent
Name (print)
Date and Place of Signing:
Signature of
Buyer/Agent
Name (print)
Date & Place of Signing:
A MINIMUM OF $10.00 IS DUE IN FEE(S) AND/OR TAX.
TREASURER¡¯S CERTIFICATE
I hereby certify that property taxes due
County on the mobile home described hereon have been paid to and
including the year
.
Date
If, in selling (or otherwise transferring ownership of) a mobile home
which possesses a tax lien, the seller does not inform the buyer (new
owner) of such a lien, the seller is guilty of deliberate deception as it
applies to Fraud and/or Theft as defined in Title 9 and 9A RCW (RCW
9.45.060, RCW 9A.56.010 (4d), and RCW 9A.56.020).
County Treasurer or Deputy
THIS SPACE - TREASURER¡¯S USE ONLY
REV 84 0003e (6/25/19) COUNTY TREASURER
Print This Form
PLEASE NOTE: This completed document cannot be
saved to your hard drive without the full version of
Adobe Acrobat. If you are not using the full version of
Adobe Acrobat, you must complete this form, then print.
MOBILE HOME
REAL ESTATE EXCISE TAX AFFIDAVIT
Submit to County Treasurer of the county
in which property is located.
Chapter 82.45 RCW
Chapter 458-61A WAC
This form is your receipt when stamped
by cashier.
FOR USE WHEN TRANSFERRING TITLE TO MOBILE HOME ONLY
PLEASE TYPE OR PRINT
INCOMPLETE AFFIDAVITS WILL NOT BE ACCEPTED
Street
City
State
Zip code
Phone number
Name
Street
City
State
Zip code
NEW REGISTERED
OWNER (Buyer)
Name
LEGAL OWNER
LOCATION OF
MOBILE HOME
REGISTERED
OWNER (Seller)
Name
Street
City
City
LIST ASSESSED VALUE(S): $
SIZE
Date of Sale
Taxable Sale Price ............................................ $
State........................................... $
0.00
Local.......................................... $
0.00
Delinquent Interest: State ............................... $
0.00
Local .............................. $
0.00
Delinquent Penalty ........................................... $
0.00
Subtotal ............................................................ $
0.00
State Technology Fee ....................................... $
5.00
Affidavit Processing Fee................................... $
5.00
Total Due .......................................................... $
10.00
Excise Tax:
Select Location
If exemption claimed, WAC number & title:
WAC No. (Sec/Sub)
WAC Title
Zip code
Street
LIST ASSESSED VALUE(S): $
MODEL
State
Name
REAL PROPERTY
PARCEL or ACCOUNT NO.
YEAR
Zip code
Phone number
PERSONAL PROPERTY
PARCEL or ACCOUNT NO.
MAKE
State
SERIAL NO. or I.D.
REVENUE TAX
CODE NO.
AFFIDAVIT
I certify under penalty of perjury under the laws of the State of
Washington that the foregoing is true and correct.
Signature of
Seller/Agent
Name (print)
Date and Place of Signing:
Signature of
Buyer/Agent
Name (print)
Date & Place of Signing:
A MINIMUM OF $10.00 IS DUE IN FEE(S) AND/OR TAX.
TREASURER¡¯S CERTIFICATE
I hereby certify that property taxes due
County on the mobile home described hereon have been paid to and
including the year
.
Date
If, in selling (or otherwise transferring ownership of) a mobile home
which possesses a tax lien, the seller does not inform the buyer (new
owner) of such a lien, the seller is guilty of deliberate deception as it
applies to Fraud and/or Theft as defined in Title 9 and 9A RCW (RCW
9.45.060, RCW 9A.56.010 (4d), and RCW 9A.56.020).
County Treasurer or Deputy
THIS SPACE - TREASURER¡¯S USE ONLY
REV 84 0003e (6/25/19) COUNTY ASSESSOR
MOBILE HOME
REAL ESTATE EXCISE TAX AFFIDAVIT
Submit to County Treasurer of the county
in which property is located.
Chapter 82.45 RCW
Chapter 458-61A WAC
This form is your receipt when stamped
by cashier.
FOR USE WHEN TRANSFERRING TITLE TO MOBILE HOME ONLY
PLEASE TYPE OR PRINT
INCOMPLETE AFFIDAVITS WILL NOT BE ACCEPTED
Street
City
State
Zip code
Phone number
Name
Street
City
State
Zip code
NEW REGISTERED
OWNER (Buyer)
Name
LEGAL OWNER
LOCATION OF
MOBILE HOME
REGISTERED
OWNER (Seller)
Name
Street
City
City
LIST ASSESSED VALUE(S): $
SIZE
Date of Sale
Taxable Sale Price ............................................ $
State........................................... $
0.00
Local..........................................$
0.00
Delinquent Interest: State ............................... $
0.00
Local ..............................$
0.00
Delinquent Penalty ........................................... $
Subtotal ............................................................ $
0.00
0.00
State Technology Fee ....................................... $
5.00
Affidavit Processing Fee................................... $
5.00
Total Due .......................................................... $
10.00
Excise Tax:
Select Location
If exemption claimed, WAC number & title:
WAC No. (Sec/Sub)
WAC Title
Zip code
Street
LIST ASSESSED VALUE(S): $
MODEL
State
Name
REAL PROPERTY
PARCEL or ACCOUNT NO.
YEAR
Zip code
Phone number
PERSONAL PROPERTY
PARCEL or ACCOUNT NO.
MAKE
State
SERIAL NO. or I.D.
REVENUE TAX
CODE NO.
AFFIDAVIT
I certify under penalty of perjury under the laws of the State of
Washington that the foregoing is true and correct.
Signature of
Seller/Agent
Name (print)
Date and Place of Signing:
Signature of
Buyer/Agent
Name (print)
Date & Place of Signing:
A MINIMUM OF $10.00 IS DUE IN FEE(S) AND/OR TAX.
TREASURER¡¯S CERTIFICATE
I hereby certify that property taxes due
County on the mobile home described hereon have been paid to and
including the year
.
Date
If, in selling (or otherwise transferring ownership of) a mobile home
which possesses a tax lien, the seller does not inform the buyer (new
owner) of such a lien, the seller is guilty of deliberate deception as it
applies to Fraud and/or Theft as defined in Title 9 and 9A RCW (RCW
9.45.060, RCW 9A.56.010 (4d), and RCW 9A.56.020).
County Treasurer or Deputy
THIS SPACE - TREASURER¡¯S USE ONLY
REV 84 0003e (6/25/19) DEPT. OF REVENUE
MOBILE HOME
REAL ESTATE EXCISE TAX AFFIDAVIT
Submit to County Treasurer of the county
in which property is located.
Chapter 82.45 RCW
Chapter 458-61A WAC
This form is your receipt when stamped
by cashier.
FOR USE WHEN TRANSFERRING TITLE TO MOBILE HOME ONLY
PLEASE TYPE OR PRINT
INCOMPLETE AFFIDAVITS WILL NOT BE ACCEPTED
Street
City
State
Zip code
Phone number
Name
Street
City
State
Zip code
NEW REGISTERED
OWNER (Buyer)
Name
LEGAL OWNER
LOCATION OF
MOBILE HOME
REGISTERED
OWNER (Seller)
Name
Street
City
City
LIST ASSESSED VALUE(S): $
SIZE
Date of Sale
Taxable Sale Price ............................................ $
State........................................... $
0.00
Local..........................................$
0.00
Delinquent Interest: State ............................... $
0.00
Local ..............................$
0.00
Delinquent Penalty ........................................... $
Subtotal ............................................................ $
0.00
0.00
State Technology Fee ....................................... $
5.00
Affidavit Processing Fee................................... $
5.00
Total Due .......................................................... $
10.00
Excise Tax:
Select Location
If exemption claimed, WAC number & title:
WAC No. (Sec/Sub)
WAC Title
Zip code
Street
LIST ASSESSED VALUE(S): $
MODEL
State
Name
REAL PROPERTY
PARCEL or ACCOUNT NO.
YEAR
Zip code
Phone number
PERSONAL PROPERTY
PARCEL or ACCOUNT NO.
MAKE
State
SERIAL NO. or I.D.
REVENUE TAX
CODE NO.
AFFIDAVIT
I certify under penalty of perjury under the laws of the State of
Washington that the foregoing is true and correct.
Signature of
Seller/Agent
Name (print)
Date and Place of Signing:
Signature of
Buyer/Agent
Name (print)
Date & Place of Signing:
A MINIMUM OF $10.00 IS DUE IN FEE(S) AND/OR TAX.
TREASURER¡¯S CERTIFICATE
I hereby certify that property taxes due
County on the mobile home described hereon have been paid to and
including the year
.
Date
If, in selling (or otherwise transferring ownership of) a mobile home
which possesses a tax lien, the seller does not inform the buyer (new
owner) of such a lien, the seller is guilty of deliberate deception as it
applies to Fraud and/or Theft as defined in Title 9 and 9A RCW (RCW
9.45.060, RCW 9A.56.010 (4d), and RCW 9A.56.020).
County Treasurer or Deputy
THIS SPACE - TREASURER¡¯S USE ONLY
REV 84 0003e (6/25/19) COUNTY AUDITOR/ LICENSING AGENT
MOBILE HOME
REAL ESTATE EXCISE TAX AFFIDAVIT
Submit to County Treasurer of the county
in which property is located.
Chapter 82.45 RCW
Chapter 458-61A WAC
This form is your receipt when stamped
by cashier.
FOR USE WHEN TRANSFERRING TITLE TO MOBILE HOME ONLY
PLEASE TYPE OR PRINT
INCOMPLETE AFFIDAVITS WILL NOT BE ACCEPTED
Street
City
State
Zip code
Phone number
Name
Street
City
State
Zip code
NEW REGISTERED
OWNER (Buyer)
Name
LEGAL OWNER
LOCATION OF
MOBILE HOME
REGISTERED
OWNER (Seller)
Name
Street
City
City
LIST ASSESSED VALUE(S): $
SIZE
Date of Sale
Taxable Sale Price ............................................ $
State........................................... $
0.00
Local..........................................$
0.00
Delinquent Interest: State ............................... $
0.00
Local ..............................$
0.00
Delinquent Penalty ........................................... $
Subtotal ............................................................ $
0.00
0.00
State Technology Fee ....................................... $
5.00
Affidavit Processing Fee................................... $
5.00
Total Due .......................................................... $
10.00
Excise Tax:
Select Location
If exemption claimed, WAC number & title:
WAC No. (Sec/Sub)
WAC Title
Zip code
Street
LIST ASSESSED VALUE(S): $
MODEL
State
Name
REAL PROPERTY
PARCEL or ACCOUNT NO.
YEAR
Zip code
Phone number
PERSONAL PROPERTY
PARCEL or ACCOUNT NO.
MAKE
State
SERIAL NO. or I.D.
REVENUE TAX
CODE NO.
AFFIDAVIT
I certify under penalty of perjury under the laws of the State of
Washington that the foregoing is true and correct.
Signature of
Seller/Agent
Name (print)
Date and Place of Signing:
Signature of
Buyer/Agent
Name (print)
Date & Place of Signing:
A MINIMUM OF $10.00 IS DUE IN FEE(S) AND/OR TAX.
TREASURER¡¯S CERTIFICATE
I hereby certify that property taxes due
County on the mobile home described hereon have been paid to and
including the year
.
Date
If, in selling (or otherwise transferring ownership of) a mobile home
which possesses a tax lien, the seller does not inform the buyer (new
owner) of such a lien, the seller is guilty of deliberate deception as it
applies to Fraud and/or Theft as defined in Title 9 and 9A RCW (RCW
9.45.060, RCW 9A.56.010 (4d), and RCW 9A.56.020).
County Treasurer or Deputy
THIS SPACE - TREASURER¡¯S USE ONLY
REV 84 0003e (6/25/19) TAXPAYER
................
................
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