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, ti u a 'sr 'X,.�su'•�F t�.��u 4 r� �a;i s1�e 5 4 ..3,."2�.':�z � /.>.� ,a.au��irii. t --t; t''�� 4y'4.� 2: �� 5ic�{�s k 3.f}14`'l p��.�y��.z�:G;� �3. Security-interest holder name: 't• Mailing address: ;a, CA Security-interest holder name: 97 Mailing address: Buyer/new owner acknowledgement of sale/change of ownership I affirm that the information provided herein accurately reflects the ownership of the structure at the completion of the sale/change of ownership. p I understand that the home cannot be relocated without first completing this form and purchasing a trip permit from the :tr, State of Oregon,Building Codes Division or one of its county agents. .cI.understand that the seller/owner is responsible for submitting this Ownership Document Application to the State of Oregon, Building Codes Division or one of its county agents within 30 days after closing of the sale,and that all . buyers and sellers will be notified by mail when the application is completed. I understand that,should the seller/owner fail to file this Ownership Document Application within 30 days,I may complete the filing[ORS 446.641(1)]. I further -0 understand that each lessor,mortgagee,trust-deed beneficiary,lien holder of record,and security-interest holder must be listed on this notice,or, if none are listed,the manufactured structure must be free and clear of all mortgages,deeds of trust,security interests,and liens. Buyer/new owner name(print): M Right of survivorship Buyer/new owner signa re: Y Date: Janice Emery4111Pr"4,c: 411P'--"1411WAry ./74,41 7' tit deer r • d Buyer/new owner name(print): ❑Right of survivorship Bu er new ownr si ature: Date: xo. Buyer/new owner name(print): ❑Right of survivorship Buyer/new owner signature: Date: Buyer/new owner name(print): ❑Right of survivorship Buyer/new owner signature: Date: Seller/current owner acknowledgement of sale/change of ownership Application must be accompanied by the appropriate valid County Manufactured Home Notification form. All owners must release,their interest or acknowledge this sale/change of ownership in the structure in order to complete this application.All current owners, including security-interest holders,must acknowledge the sale/change of ownership by signing therpwnership document or DMV title or completing the section below. Security-interest holders may elect to acknowledgir the sale/change of ownership, but maintain their security interest until such time as they no longer have an interest inthe home. Seller/current owner affidavit I affirm that I am the current owner of this structure and acknowledge that the seller is responsible for submitting notice of sale/change of ownership to the State of Oregon Building Codes Division or one of its county agents within 3n days of the closing of the sale[ORS 446.641(1)]. 440-2952(7/17/COM) Page 4