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I further certify that each lessor,mortgagee,trust-deed beneficiary,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. Seller/current owner name(print): Seller/current owner signature: Date: Q I release my interest in this structure. Christine M.Welch,Successor I acknowledge this sale/change of ownership, Phone: ��/,C� //a2,64-1-4,1„2.- /,e1-/ ❑ but do not release my interest in the structure. Email: / �Gc Seller/current owner name(print): Se er/current owner signature: Date: Q I release my interest in this structure. Jack N. Belleque Successor Phone: 6441 i'i.e' ,(-e-i,„ 11-I D-f 17 ❑ I acknowledge this sale/change of ownership, but do not release my interest in the structure. Email: Seller/current owner name(print): Seller/current owner signature: Date: 0 1 release my interest in this structure. Phone' ❑ I acknowledge this sale/change of ownership, 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: SECURITY INTEREST HOLDER ALREADY ON RECORD(if applicable) 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. •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 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 ❑ If recording in or 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. 440.29527/17/CO� Page 5 �