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I further certify that each lessor, mortgagee,trust-deedbeneficiary,lien holder of record, and security-interest holder has been listed on this notice, or if none are listed, that this structure is free and clear of all mortgages, deeds of trust,security interests, and liens and that I have the legal right to sell this manufactured structure. f 1 Seller/current owner name(print): Seller/curwit owner signature: Date: I release my interest in this structure. LEISURELAND'HOMES INC Phone: Email: yam~ °Fi bI uutckndowLterdeglathseismsyalie/ntchan eetgeintfwructutirpe,.r Seller/current owner name(print): Sellerlcurrent owner signature: " Date: ❑ Ircicasemy-interest in this'sn,icture. 1 Phone' ❑ I acknowledge this sale/cliange of ownership; but do+not releasc.my interest in the structure. Email: Seller/current owner name(print): Seller/current.owner signature: "Date: ❑ I.release my interest in this structure. I acknowledge this rule/change of ownership, Phone: ❑ but do not release my interest ip.the structure. Email: Seller:/current owner.name(print): Seller/current owner signature: Date: ❑ I release my interest in this structure. Phone: ❑ I acknowledge this saleichange of ownership, but do not release my interest in the structure. Email: f`SECU ITY IN EREST HOLDER ALREADY ON RECORD if a licable u tr x` Security holder's name(print):. Security holder's signature: Date: E❑ r release my i terest.in this,structure. 1 acknowledge this sale/change of ownership, but do not release my interest in the structure. Security holder's name(print): Security holder's signature: Date: ❑ I release my interest in this structure. ❑ I acknowledge this sale/change of ownership, but do not release my interest in the structure. PRIOR TO SUBMITTING, CHECK.THE'FOLLOWING '_ ❑ Signatures from all applicable parties must be complete(current owners/sellers,new owners/buyers, and security interest holders).. ❑ A valid tax certification:from the county tax assessor.,The tax certification form will be provided by the county office and must be signed by a county official, ❑ Any additional documents needed to establish your authority to buy/sell this home as required by ORS 446 and OAR 918 and posted at www.oregon.gov/bcd. If the home is being moved to a chffeient county, a:valid tax certification formis needed from both: ❑ (A) the county the home is moving froth-and (B)the county the home will be moved to ❑ If recording inor removing from county deed records,you must also submit.a copy of the recorded application (Form 5176 or 5175 found at www.oregon.gov/bcd). ❑ If signing by Power of Attorney, submit a Change Affidavit(Form 5221). ❑ If this application is being submitted by the seller,you must also submit a bill,of sale. 440-2952(7/19/COM) Page.5