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1335313 • 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: E I release niy interest in this structure. CLAYTON HOMES ALBANY, OR • Phone:(541)967-8555 ❑I acknowledge this sale/change of ownership, Email: I 10 J 9' but do not release my interest in the structure. Seller/current owner name(print) Seller/c rrent owner signature: Date: ` ❑I release my interest in this structure. Phone: 11:1I 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: 0 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: Ef 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 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). El If this application is being submitted by the seller,you must also submit a bill of sale. • • 440-2952(7/17/COM) OR Title,Appl ication-10/2018-TitleAppi 1211 - Page 5 004175519-00001