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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: C. Sv.,,-,-, c-.. (. I.,,,tw .--L_ILC--.,
<br /> ADDRESS: 3737 Palm Harbor Drive,Millersburg,OR 97321 Address: \�Z\S cv�1 Ct-�,•.ti+... wear-c , 2?.A. �r=�,-\t r'J ...2. '' "
<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 manuf _./.
<br /> actured home described.below, Dated at
<br /> the property of said MANUFACTURER,has been transferredC. �„.
<br /> this 17th dayof February , 2025 on Invoice No 202492068400 Transferor(Finn Name) r/ ign Here
<br /> Position
<br /> Dealer License(Permit)No. �\^SC ?/
<br /> Before me personally appeared ('trc--i ( r-.....rw'' who by me being
<br /> To: COMMONWEALTH HOMEOWNER SERVICES,INC. duly sworn'mon oath says that the statements set forth above are title and correct.
<br /> -0 uescribed p eI n F me this 1--k day of i4"-o,.� �'S
<br /> Distributor,Dealer,Etc. Kf
<br /> Ott;.,% ,. ._ n.,, •.ry Public for l no. .1,� s�.-� County,State of ?�sei erg
<br /> Whose Address is: 18150 SW BOONES FERRY ROAD .fir-, . NA WUBUC-OREGON
<br /> �; COMMISSION NO.1014450 SECOND ASSIGNMENT
<br /> Street MY COM+(MIS�IIQIi FSR q 'prvi he-eby 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-400-28523A 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: 3104G28523A Body Width Ft: 27'0"
<br /> Body Length Ft: 56'0" /Ft: 52'0" Dated at
<br /> By:
<br /> Including Hitch Excluding Hitch
<br /> Transferor(Firm Name) Sign Here Position
<br /> Square Feet: 1350 Date of Manufacture: 02/11/2025 Dealer.License(Permit)No.
<br /> Before me personally appeared who by me being
<br /> duly sworn upon oath says that the statements set forth above are true and correct.
<br /> Manufacturer's ID No: PHH310OR25-16294A Weight: 19,788 Subscribed and sworn to before me this day of , .
<br /> Manufacturer's ID No: PHH3100R25-16294E Weight: 20,904 • 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 /> •
<br /> 4
<br /> Palm Harbor Ho Dated at
<br /> • By:
<br /> Corp ation Transferor(Firm Name) 'Sign Here Position
<br /> Dealer License(Permit)No.
<br /> By:_cc/4j r -- .X 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 County,
<br /> Public for State of
<br /> Office Address of Signatory(City&State) Notary Seal
<br />
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