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MANUFACTURER'S STATEMENT OR CERTIFICATE OF ORIGIN TO A MANUFACTURED HOME •
<br /> FIRST ASSIGNMENT
<br /> MANUFACTURER:Palm Harbor Homes For Value Received,the undersigned hereby transfers this Statement of Origin and the manufactured
<br /> home described therein to: CAA' S,A1.o.\A; Q ' a.-Na L,.,,K. ,__,'
<br /> ADDRESS: 3737 Palm Harbor Drive, Millersburg,OR 97321 • Address: tgl,b C3or,� �n.. c2 !, L? <'c\c \. i1 q� t4
<br /> and certifies that the home is new and has not been registered in this or any other state;;he also warrants
<br /> Street,City,State,and Zip the title of said home at time of delivery,subject to the liens and encumbrances,if any,as set out below
<br /> Amt.Of Lien Date To Whom Due Address
<br /> --- _..
<br /> The undersigned MANUFACTURER hereby certifies that the new manufactured home described below, Dated • at �.-r
<br /> 7
<br /> the property of said MANUFACTURER,has been transferred l'�, V, t i, ," , ,,, PA, ,. By,
<br /> Transferor(Firm Name) f Sigh here
<br /> this 21st day of February , 2025 on Invoice No 202492072000 f /Position
<br /> Dealer License(Permit)No, �'�S�4 ' a��r'"J
<br /> Before me personally appeared C j,,,-' ‹ BOA,..... % r,,,-' who by me being
<br /> To: COMMONWEALTH HOMEOWNER SERVICES,INC. duly sworn upon oath says that the statements set forth above are true and correct.
<br /> '--
<br /> Distributor,Dealer,Etc. Subsc fil�before me this t� 'day of 'r"c.z„,A...- a0;.41\
<br /> tt A ,; M AK tge CA Notary P rblic for t t v,r,,\- ..r c! �, County,State of i..3t�f ,-
<br /> t- '4 .. NOTARbhP)1!BlydC-OREGON "
<br /> Whose Address is: 18150 SW BOONES FERRY ROAD � n COMMISSION NO.1014450 SECOND ASSIGNMENT
<br /> Street MY COM V114§1CinignEtWilltitRaiMgned hereby transfers this Statement of Origin and the manufactured
<br /> PORTLAND,OR 97224 home described therein to:
<br /> City,State,and Zip Address:
<br /> and certifies that the home is new and has not been registered in this or any other state;he also warrants
<br /> Trade Name: 3104G-400-28563E Model Year: 2025 the title of said home at time of delivery,subject to the liens and encumbrances,if any,as set out below
<br /> Amt.Of Lien Date To Whom Due Address
<br /> Model No: 3104G28563B _ Body Width Ft: 27'0"
<br /> Body Length Ft: 60'0" /Ft: 56'0" Dated at
<br /> Including Hitch Excluding Hitch By:
<br /> Transferor(Firm Name) Sign Here Position
<br /> Square Feet: 1445 Date of Manufacture: 02/20/2025 Dealer License(Permit)No.
<br /> Before me personally appeared who by me being
<br /> Manufacturer's ID No: PHH3100R25-16302A Weight: 26,364.. duly sworn upon oath says that the statements set forth above are true and correct.
<br /> Subscribed and sworn to before me this day of ,
<br /> Manufacturer's ID No: PHH3100R25-16302B Weight: 20,628 Notary Public for County,State of
<br /> Manufacturer's ID No: Weight: Notary Seal
<br /> • THIRD ASSIGNMENT
<br /> Manufacturer's ID No: Weight: For Value Received,the undersigned hereby transfers this Statement of Origin and the manufactured
<br /> Manufacturer's ID No: Weight: home described therein to:.
<br /> Manufacturer's ID No: Weight: Address:
<br /> and certifies that the home is new and has not been registered in this or any other state;he also warrants
<br /> the title of said home at time of delivery,subject to the liens and encumbrances,if any,as set out below
<br /> The CORPORATION further Certifies that this was the first transfer of such new manufactured home in 'Amt.Of Lien Date To Whom Due Address
<br /> ordinary trade and commerce. •
<br /> Palm Harbo omps Dated at
<br /> By:
<br /> Corp lion / ✓ Transferor(Firm Name) Sign Here Position
<br /> Eq.:,... � F ) � Dealer License(Pemut)No.
<br /> ___ Before me personally appeared who by me being
<br /> Sign Name Title or Position duly sworn upon oath says that the statements set forth above are true and correct.
<br /> 3737 Palm Harbor Drive,Millersburg,OR 97321 Subscribed and sworn to before me this day of ,
<br /> Notary Public for County,State of
<br /> Office Address of Signatory(City&State)
<br /> Notary Seal
<br />
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