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• , . 1 1300214 __ _ _ _ _ — — .—.•-- -- II further certify that each lessor,mortgagee,tnlst-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. f 1 Seller/current owner name(print) Seller/current owner signature: f Date:T— I.0 I release my interest in this structure. CLAYTON HOMES ALBANY,OR i Phone:(541)967-8555 r ii" A 6117110 I acknowledge this sale/change of ownemb ,, ( ) ; i. I- t`t 4 'etnC •- 47- 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. IPhone: j 0 I acknowledge this salechange of ownership, Email: i but do not release my interest in the structure. — Seller/current owner name(print) Seller/current owner signature: Date: ElI release my interest in this structure. IPhone: 0 1 acknowledge this sale/change of ownership, but do not release my interest in the structure. i • I Email: t ___ —.- Seller/current owner name(print) I Seller/current owner signature: Date: El I release my interest in this structure. j Phone: E I acknowledge this sate/change of ownership, Email: – but do not release my interest in the strum:nu SECURITY INTEREST HOLDER ALREADY ON RECORD (If applicable) ESecurity holder's name(print) Security holder's signature: i Date: '❑I release my interest in this structure. —) l Q I acknowledge this sale/change of ownership, but do not release my interest in the sttuchrm Security holder's name(print) Security holder's signature: ;Date: i Q I release my interest in this structure. W �`�^ I acknowledge this salr/change of ownership, _ but do not release my interest in the structure.' PRIOR TO SUBMITTING,CHECK THE FOLLC 11NG: 1[]Signatures from all applicable parties must be complete(current owners/sellers,new miners/buyers,and security interest holders). _ ___ 0 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. . Q Any additional documents needed to establish your authority to buy/sell this home as r aired by ORS 446 1- and OAR 918 and posted at www.oregon.gov/bcd. Q If the home is being moved to a different county,a valid tax certification form is neede from both: (A)the county the home is moving from and i (B)the county the home will be moved to i❑If recording in or removing from county deed records,you must also submit a copy of t tie recorded 1 application(Form 5176 or 5175 found at www.oregon.gov/bcd) _ __ Q If signing by Power of Attorney,submit a Change Affidavit(Form 5221). 0 If this application is being submitted by the seller,you must also submit a bill of sale. 440-2952(7/17/COM) OR Title Application-12/2017.TitleAppl 1211 Page 5 004085888-00002