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I T' ther certify that each:lessor;mortgagee,trust-deed beneficiary,lien holder of record,and security-interest • :: :Bolder has been listed on this notice,or.if none are listed,that this structure is free and clear of all mortgages, • deeds-oftrust,:security interests,and liens and that I have the legal right to sell this manufactured structure. Seller/current owner name(print): Seller/current owner signature: Date: Q I release my interest in this structure. :l&M Homes,LLC • Phone:503-908-8166 • 4/1471,ain j ❑ I acknowledge this sale/change of ownership, Email:tmelchlor jandmhomesd tqt, V. /, ) j but do not release my interest in(he structure. Seller/current owner name(print): Seller/current owner signature: Date: ❑ I release my interest in this structure. Phone: ❑ Iacknowledge this saleJchangeofownership, but do not release my interest in the structure. Email: - Seller/current owner name(print): Seller/current owner signature: Date: ❑ I release my interest in this structure. Phone: • ❑ I acknowledge this sale/change of ownership, but do not release my interest in the structure. Email: _ ,Sellar:/current owner name(print): Seller/current owner signature: Date: ❑ I release my interest in this structure, • Phone: r-1 I acknowledge this sale/change of ownership, 1-1 but do not release my interest in the structure. -• -Email: • SECURITY INTEREST HOLDER ALREADY ON RECORD(if applicable) i etirit holder's name(print):•• Seeurit -j�oldei t'a signature: Date: 0 I release my interest in this structure. t : . t-: - :, ;1,,;.;,i� 1 ••. • • ❑ I 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, i'-. : . • 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). , ,;- •. . oA 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 docuznnts 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 different county,a valid tax certification form is needed from both: ❑ (A)`the county the home is moving from and , :(B)the county the home will be moved'to• •• - I recording in or removing from county deed records,you must also submit a copy of the recorded . ' "4•:i-vacation(Form 5176 or 5175 found at www.oregon.gov/bcd) ' : :O Ttsigning by Power of Attorney,submit a-Change•Affidavit,(Form 5221). . .. • .❑ Ifftliis application is being submitted bythe,:seller,:you must also submit a bill of sale. 4404952(7/17/COM) . . ; • Page 5 •