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Deed of Dedication/DEEDofDEDICATION.doc\ SMT Page 1 of 4 FORM 04 0001/bh Return Address: City Clerk’s Office City of Renton 1055 South Grady Way Renton, WA 98057 DEED OF DEDICATION Property Tax Parcel Number: Project File #: Street Intersection: Reference Number(s) of Documents assigned or released: Additional reference numbers are on page _____. Grantor(s): Grantee: 1. 2. City of Renton, a Washington Municipal Corporation LEGAL DESCRIPTION: (Abbreviated or full legal must go here. Additional legal on page_______) The Grantor, _________________________, for and in consideration of mutual benefits conveys, quit claims, and dedicates to the Grantee, the City of Renton, the above described real estate situated in the County of King, State of Washington. IN WITNESS WHEREOF, I have hereunto set my hand and seal the day and year as written below. Grantor(s): Dated: INDIVIDUAL FORM OF ACKNOWLEDGMENT STATE OF WASHINGTON ) SS COUNTY OF KING ) I certify that I know or have satisfactory evidence that ______________________ Notary Seal must be within box ________________________________________ signed this instrument and acknowledged it to be his/her/their free and voluntary act for the uses and purposes mentioned in the instrument. Notary Public in and for the State of Washington Notary (Print)_____________________________________ My appointment expires:____________________________ Dated: /DEEDofDEDICATION.doc\ SMT Page 2 of 4 FORM 04 0001/bh REPRESENTATIVE FORM OF ACKNOWLEDGMENT STATE OF WASHINGTON ) SS COUNTY OF KING ) I certify that I know or have satisfactory evidence that ______________________ Notary Seal must be within box ________________________________________ signed this instrument and acknowledged it to be his/her/their free and voluntary act for the uses and purposes mentioned in the instrument. Notary Public in and for the State of Washington Notary (Print)_____________________________________ My appointment expires:____________________________ Dated: CORPORTATE FORM OF ACKNOWLEDGMENT STATE OF WASHINGTON ) SS COUNTY OF KING ) I certify that I know or have satisfactory evidence that ______________________ Notary Seal must be within box ________________________________________ signed this instrument and acknowledged it to be his/her/their free and voluntary act for the uses and purposes mentioned in the instrument. Notary Public in and for the State of Washington Notary (Print)_____________________________________ My appointment expires:____________________________ Dated: Accepted by the City of Renton: By: ________________________________ Mayor Attest: By: ______________________________ City Clerk /DEEDofDEDICATION.doc\ SMT Page 3 of 4 FORM 04 0001/bh Exhibit A Legal Description Project: WO# PID GRANTOR: Street: /DEEDofDEDICATION.doc\ SMT Page 4 of 4 FORM 04 0001/bh Map Exhibit