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0 <br /> °---c). Affidavit to Establish Ownership ° <br /> .adz 0, <br /> 1�1; ., �z of a Manufactured Structure <br /> s Department of Consumer and Business Services <br /> Building Codes Division <br /> Web:bcd.oregon.gov <br /> HOM INFORMATION <br /> Home ID number(ifknown): V Vv' 631,0 In (('V DMV X-plate number(if known): I 113809 <br /> TITLE/OWNE SHIP INFORMATION <br /> (To be used if a title or ownership document is unavailable) <br /> Applicant's name(last,first,middle): Phone: ( ) <br /> Address: - <br /> City: State: ZIP: <br /> Manufacturer: O(,L,W f' Year: 11(p <br /> Serial number: 1(0(D HUD label numbers: <br /> ❑ I am the sole owner of the structure described above. <br /> ❑ The following persons are the owners of the structure described above.This is a complete list of all persons holding interest <br /> in this structure.Attach a separate sheet listing all owners if more space is required. • <br /> (1) — (2) (3) - <br /> List all security interest or liens that have been held on this structure.Attach additional pages, ifnecessary. <br /> Is this structure registered or titled,or has it ever been registered or titled,in another state or jurisdiction? <br /> ❑Yes ❑No ❑Unknown Where: Registration/title no.: <br /> Did you buy this structure new or used? <br /> ❑New ❑Used Date of purchase: State/county: <br /> Name of person or company purchased from: <br /> Address: City: State: ZIP: <br /> REQUIRED DOCUMENTATION INFORMATION <br /> Explain why you are unable to provide the documents required to prove ownership of this structure.Attach additional pages, <br /> ifnecessary. <br /> The following documents are attached for consideration in my claim of ownership.(Check all that apply.): <br /> ❑Bill of sale ❑Inheritance affidavit <br /> ❑Proof of taxes paid ❑Any security holder agreements/release notices <br /> ❑Proof of insurance paid ❑Other: <br /> 1- <br /> rtf,CCO�NSUM�ER <br /> Il IXSERVICES <br /> 440-2947(5/11/COM) <br />