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1353699 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) Selle • •I •wner signature: Date: EN release my interest in this structure. CLAYTON HOMES ALBANY, OR2,1 Phone:(541)967-8555 i 1 bJ I acknowledge this sale/change of ownership, Email: ♦ I but do not release my interest in the structure. Seller/current owner name(print) Seller/current owner s''nature: Date: D I release my interest in this structure. Phone: p 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: D 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: 1 release my interest in this structure. Phone: [J 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 bolder's name(print) Security holder's signature: Date: E 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: D I release my interest in this structure. ID I acknowledge this sale/change of ownership, but do not release my interest in the structure. PRIOR TO SUBMITTING,CHECK THE FOLLOWING: n 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 0 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) 0 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-10/2018-TitleApp11211 Page 5 004222708-00001