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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/cu nt wiser mane rim): SellerIunrrent wiser signature: Dote: [ I release my interest in this structure. r�E, s.sckf° Da Ve�/' I I ae.knowle[ge this salekbange of ownership, Email: 1 ' �— e if-d.)?'4 ❑ but do not release my interest in the structure. Email:nu•.! ,.- �(F,S st e�I(A oa d CCs "'� Seller/current owner name(print): SS3eell��iar/current owner el ature: Date: I release my interest in this stmcmre. 1 7-4 e`t ri 5 Y/ —�-'C' I ❑ I acknowledge this sale/change of ownership, Emailt (-(-�� ,e /�, but do not release my interest in the structure. Email:��` °�-� 1 t-'� Seller/current owner name(print): Seller/current owner signature: Date: ❑ I release my interest in this structure. ❑ I acknowledge this saleicbenge of ownership, Phone: but do not release my interest in the structure. Email: Seller./current owner name(print): Setter/current owner signature: Date: ❑ I release my interest in this s[tueture. ❑ I acknowledge this sale/cltange of ownership, Phone: but do not release my interest in the structure. Email: SECURITY-INTEREST HOLDER ALREADY ON RECORD(If applicable) • Security holder's signature: Date: 0 [release my interest in this structure. Security holder's name(print): 1--1I acknowledge this sale/change of ownership, but do not release my interest in the structure. Security holder's signature: Date: 0 [release my interest in this sbncture. Security holder's name(print): ❑ I acknowledge this saleichange 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). ❑ If this application is being submitted by the seller,you must also submit a bill of sale. 440-2952(7/I9ICOM) Page 5