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• 1308543 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. CLAYTON HOMES ALBANY, OR Phone:(541)967-8555 ❑I acknowledge this sale/change of ownership, Email: J „0, ,` but do not release my interest in the structure. •Seller/current owner name(print) Seller/tarrent 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: LI I release my interest in this structure. J 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. 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 illy: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: U Signatures from all applicable parties must be complete(current owners/sellers,new owners/buyers,and security interest holders). (l 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. I' ]If the home is being moved to a different county,a valid tax certification form is needed from both: 1: (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). n 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-10/2018-TitleAppl 1211 Page 5 004107883-00001