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<br /> MANUFACTURER'S STATEMENT OR CERTIFICATE OF ORIGIN TO A MANUFACTURED HOME
<br /> FIRST ASSIGNMENT
<br /> MANUFACTURER:Palm Harbor Homes - For Value Received,the undersigned hereby transfers this Statement of Origin and the manufactured
<br /> home descri�b7e therein to: CA--L. 5�,,�A„r,,C+. [��,.,,-_,,,- I L C`
<br /> Address: 1'`d\SC, `;'.. i ( -,r....� —a...rc�,\ .. A �,f Nr\/l-.r (�_. cti-V .W,
<br /> ADDRESS: 3737 Palm Harbor Drive, Millersburg,OR 97321 • and certifies that the home is new and has not been registered in this dr any other state;he also warrants
<br /> - , Street,City.Stare,and Zip the title of said home at time of delivery,subject to the liens and encumbrances,if any,as set out below
<br /> Amt.Of Lien Date To Whom Due Address •
<br />• The undersigned MANUFACTURER hereby certified that the new manufactured home described below, Dated at / /
<br /> the property of said MANUFACTURER,has been transferred r `\ i] J l/
<br /> this 31st day of January , 2025 on Invoice No 202492086100 Transferor(Firm Name) ign Here //// Po�ifion
<br /> Dealer License(Permit)No. \�C n r-
<br /> Before me personally appeared . CSete---"-c,,., • ,A who by me being
<br /> To: COMMONWEALTH HOMEOWNER SERVICES, INC. duly sworn upon oath says that tte statements set forth above are truaind correct.
<br /> 400 , Subs jtitmg swopbefore ne this \‘-'\ 'n day of ,i A , jaS
<br /> Distributor,Dealer,Etc.
<br /> t:- .:: •^ MEUSA COOK Notary Public for 1��rN.:>\'-\. �rft--.� County,State of 'act„-.
<br /> `k�" NOTARA6RUA1171-OREGON
<br /> Whose Address is: 18150 SW BOONES FERRY ROAD1
<br /> d.
<br /> COMMISSION NO.1014450 SECOND ASSIGNMENT
<br /> Street MY COMMS I F PIKAdRiQP..g-EK,;31ed hereby transfers this Statement of Origin and the manufactured
<br /> PORTLAND, OR 97224 home described therein to:
<br /> City,Slate,and Zip Address:
<br /> and certifies that the home is new and has not been registered in this or any other state;he also warrants
<br /> Trade Name: 3104G-400-28441A Model Year: 2025 the title of said home at time of delivery,subject to the liens and encumbrances,if any,as set out below
<br /> Amt.Of Lien Date To Whom Due Address
<br /> Model No: 3104G28441A Body Width Ft: 27'0"
<br /> Body Length Ft: 54'8" /Ft: 50'8" Dated , at
<br /> Including Hitch Excluding Hitch By:
<br /> Transferor(Firm Name) Sign Here Position
<br /> Square Feet: 1188 Date of Manufacture: 01/31/2025 Dealer License(Permit)No.
<br /> Before me personally appeared who by me being
<br /> duly sworn upon oath says that the statements set forth above are true and correct.
<br /> Manufacturer's ID No: PHH3100R24-16284A Weight: 20,976 Subscribed and sworn to before me this day of ,
<br /> Manufacturer's ID No: PHH310OR24-16284B Weight: 19,188 Notary Public for County,State of
<br /> Manufacturer's ID No: Weight: Notary Seal
<br /> THIRD ASSIGNMENT
<br /> Manufacturer's ID No: Weight: For Value Received,the undersigned hereby transfers this Statement of Origin and the manufactured
<br /> Manufacturer's ID No: Weight: home described therein to:
<br /> Manufacturer's ID No: Weight: Address:
<br /> and certifies that the home is new and has not been registered in this or any other state;he also warrants
<br /> the title of said home at time of delivery,subject to the liens and encumbrances,if any,as set out below
<br /> The CORPORATION further Certifies that this was the first transfer of such new manufactured home in Amt.Of Lien Date To Whom Due Address
<br /> ordinary trade and commerce.
<br /> •
<br /> Palm Herb omes Dated at
<br /> • - By:
<br /> Corp ration j //
<br /> ______:__________frz......fed.sv
<br /> Transferor(Firm Name) Sign Here • Position
<br /> ,�/ 'Dealer License(Permit)No.
<br /> By: �- Gr" ^"'` Before me personally appeared who by me being
<br /> Sign Name Title m Position . duly sworn upon oath says that the statements set forth above are true and correct.
<br /> 3737 Palm Harbor Drive, Millersburg,OR 97321 Subscribed and sworn to before me this day of
<br /> Notary Public for County,State of
<br /> Office Address of Signatory(City&State) Notary Seal
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