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✓s:1.111On o l' W UWN K ACKNOWLEDGEMENT(One name per box) 6 • 0 Person ❑Business R Trust 0 Guardian r, Legal Name: p,4�� cc , (last,first,middle) 4t t F�4.�l t of .A ex 1;4 f�'1/ierieti5T 4117 f 24 Phone: 51)3 93 i if23-ef Z Mailing Address: CI t 4kt Ai J CVOA k14 OCity: S.hl evl State: oy2 ZIP: 973 GCf Email: IfrAh -t u'AA ® cyy V•t M t...c .Wi u1 Right of ❑Yes No Z Survivorship: ❑ Signature: °"` Lqr. Date: ?f(+(zi— p Person ❑Business ❑Trust ❑Guardian N Legal Name: Phone: CC (last,Just,middle) Z Mailing Address: 0 City: State: ZIP: Email: W Right of ❑Yes ❑No Z Survivorship: Signature: Date: ❑Person ❑Business 0 Trust 0 Guardian M Legal Name: Phone: CC (last,first,middle) Z Mailing Address: OCity: State: ZIP: r Email: W Right of ❑Yes ❑No • Z Survivorship: Signature: Date: ❑Person 0 Business 0 Trust ❑Guardian v Lcgal Name: ce (last,first,middle) Phone: Z Mailing Address: OCity: State: ZIP: Email: LEI Right of ❑Yes ❑No Z _ Survivorship: Signature: Date: NEW OWNER ACKNOWLEDGEMENT OF SALE/CHANGE OF OWNERSHIP I affirm that the information provided herein accurately reflects the ownership of the structure at the completion of the sale or change of ownership.I understand that the home cannot be relocated without first completing this application and purchasing a trip permit from the Building Codes Division or through one of its county agents. I understand that the seller/owner is responsible for submitting this application within 30 days after the close of the sale,and that all buyers and sellers will be notified by mail when the application is approved. If the application has not been submitted after 30 days,I may complete the filing under ORS 446 64(1). I understand that each lessor,mortgagee,trust-deed beneficiary,lien holder of record,and security interest holder must be listed on this notice.If none are listed,the structure must be free and clear of all mortgages,deeds of trust,security interests,and liens. Page 3