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I further certify that each lessor,mortgagee,trust-deed beneficiary,lien holder of record, and security-interest holder has been listedon 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 sellthis manufactured 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, but do not release my interest.iu the structure. Emai'1: 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 notrelease 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: Seller:/current owner name(print): Seller/current owner signature: Date: ❑ I release my interest in this structure. Phone: ❑ Iacknowledge 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: EII release my interest in this.structure. ❑ I acknowledge this sale%hange 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 alsosubmit a copy of the recorded application(Form 5176 or 5175 found at www.oregon.govlbcd) ❑ If signing by Power of Attorney, submit a Change Affidavit(Form 5221). El If this application is being submitted by the seller,you must also submit a bill of sale. • 440-2952(7/17/COM) Page 5 •