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Affidavit of Transfer of Interest by r:: i Inheritance without Probate Department of Consumer&Business Services Building Codes Division Web:oregon.gov/bcd HOME INFORMATION Home ID number(if known): DMV X plate number(ifknown):%//'3 g b 9 AFFIDAVIT INFORMATION - , Applicants may want to seek legal counsel to determine heirs. All heirs must sign a completed affidavit.If there is more than one heir,each heir must complete and sign this affidavit or sign a duplicate of this affidavit.If there are any material differences between duplicate affidavits,all of the affidavits will be rejected.If the heir is a minor or is incapacitated,the parent or guardian must sign for the heir. Submit this affidavit along with a Bill of Sale/Change Application(440-2952),and a County Manufactured Home Notification and Tax Certification for Used Homes(440-5158)to the State of Oregon Building Codes Division or one of its county agents. HEIR INFORMATION' I/we,declare that-4")/4-.iy/?7 y , I. Kt)4 IO died on the ., c' T---- day of'rdC.T w k.e b-. that the estate has not and will not be probated and that Uwe posses a copy of the death certificate. At the time of death,the deceased held an interest in the following describe manufactured home: Location:3o9 LA-60a ac�p �; c��kar 4� -.i.7 0_3.7_ Manufacturer: Year: j 96'1 Serial number: 5 //04 HUD label number: X Eg Deceased was an owner of the home. ❑Deceased held a security interest in the home. The deceased's interest in the above-described home has passed to: (1)Name: x;050-'A L M '-"S Address: "72 E S-F-- "--Al2-T1(-- '7T7 AJj (--- - - City,state,ZIP: f'o.C.T tA4--0 ;02 c:-1 7 "2-04, (2)Name: Address: ' City,state,ZIP: SIGNATURES _ , ALL HEIRS MUST SIGN BELOW I hereby attest that I am an heir to the interest transferred on this form and that all the information provided on this form is true and accurate,to the best of my knowledge. U5H0A 1, Alik-`�5 , 7. - ---`- Print name: ,� SignatureG%" State of Op e.los en County of 1).1 a r.,;OA Signed and sworn to(or affirmed)before me on (tau (eet. ,S,2.o)9 (date)by - - ail\ ,. , E Kr t;C, r, o�o OFFICIAL STAMP Notary P t#-="1";:i..4‘o ADAM JOSEPH EHRLICHER I N.t 1".±++n', NOTARY PUBLIC-OREGON , COMMISSION NO.983501 ' '859 MY COMMISSION EXPIRES FEBRUARY 03,2023 1 (Notary seal) IQ DEPART��t1ENTOF CO USIi E S SERVICES . 440-2946(1/17/COM)