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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: ❑ I release my interest in this structure. LeiStirel&4 tl Fps . Phone: / / [1 I acknowledge this sale/change of ownership, Email: j� ��,�� / ..I_,`Q !� but de not release my interest in the structure. Seller/current owner name(print): Seller/current owner signature: Date: 9 ❑ I release my interest in this structure. Phone: I acknowledge this.sale/change of ownership;. Email: ❑ but do not release my interest in the structure. 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, Email: ❑ but do not release my interest in the structure. 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, $majl; ❑ but do not release my interest in the structure. =SrCURITYlNTER'EST01OLD:ER AL4R,E ADY OSI RE•CORD1fa0:licable Security holder's signature: Date: ❑ I release my interest in:this structure. Security holder's name(print): ❑ I acknowledge this sale/change of,ownership, but do not release my interest in the structure. Security holder's signature: Date: ❑ I release my interest in this structure. Security holder's name(print): l acknowledge this sale/change:of ownership, but do not release my interest to the structure P (OI2 TO SU3B(VIITIING, CFFE • G CTH t�ol✓LowC�c °" ;i ;` ❑ 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 bythe county office and must be signed by a county official, ❑ Any additional documents needed to establish your authority to buy/sell this_homeas 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, Change Affidavit(Form.5221). ❑ If this application is being submitted by the seller, you must also submit a bill of sale, 440-2952(7/17/COM) Page 5