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i further certify that each lessor, mortgagee, trust-deed beneficiary, lienholder of record, and security-interest holder has been listed on this notice, or if none are listed, that this structuremis 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: 0 i release my interest in this structure. J & M Homes, LLC Phone: 503-908-8166 ❑ I acknowledge this sale/change of ownership, Email: bbaxter@jandmhomes.co but do not release my interest in the_structure. Seller/current owner name(print): Seller/current owner signature: Date: ❑ I release my interest in thisstructure. Phone ❑ I acknowledge this sale/change of ownership, but do not release my interest in the structure. Email: • Seller/current owner name(p•ini): Seller/current owner signature: Date: ❑ I release my interest in this structure. • Phone: ❑ I acknowledge this sale/change of ownership, but,do not release my interest in the structure. Entail: Seller:/current owner name(print): Seller/current owner signature: Date: ❑ l.release niy interest in this structure. Phone: 0 l acknowledge this sale/change of ownership, but do not release my interest in the structure. Email: SECURITY INTEREST HOLDERrALRE ADYON RECORD (tf appltcable)k Security holder's name(print): Security holder's signature: Date: 111 (_release my interest in this structure. 1-1 but this sale/change of ownership, bit do not release my interest in the structure. Security holder's name(prim): Security holder's signature: Date: ❑ i release my interest in this structure. ❑ I acknowledge this sale/change bf ownership, but do not release my interest in the structure. PRIOR T 0 tijBMITTING, 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 doc lments 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(7117/C0N7) Page 5