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' ? , Affidavit in Support of Change to a Manufactured Home <br /> p" . `-' Department of Consumer and Business Services <br /> . Building Codes Division <br /> 1535 Edgewater St.NW, Salem, Oregon•Phone: 503-378-4530 • Fax: 503-378-4101 <br /> Web: oregon.gov/bcd <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): X217569 <br /> AFFIDAVIT INFORMATION <br /> This affidavit can be used to support ownership changes without the applicant being required to submit legal documents <br /> and must be submitted along with a Manufactured Home Ownership Document Application for New and Used Homes <br /> (440-2952)and a valid tax certification,signed by the county in which the home resides. <br /> APPLICANT/OWNERSHIP INFORMATION <br /> Applicant's name(last,first,middle): Jensen, Kathleen M Phone: <br /> Address:PO Box 1086 <br /> City:Silverton State:OR ZIP:97381 <br /> Email: <br /> HOME INFORMATION <br /> Manufacturer: Berkshire Year: 1992 <br /> Serial number: ORFLN48AB1442OBS HUD label numbers: <br /> ❑ I am a co-owner of the manufactured home identified above and am listed with a right of survivorship with(list all <br /> owners) <br /> I affirm that <br /> is/are deceased and that I possess a copy of the death certificate(s). <br /> 0 I affirm that if the buyer,new owner, or seller is a trust or conservatorship,that I am an authorized representative of <br /> the trust or conservatorship and that I have the legal standing to sign for the trust or conservatorship. <br /> ❑ I affirm that, if ownership is transferring because of a divorce, I have been awarded sole ownership of this <br /> manufactured home and possess a copy of the court order with case number stating that award. <br /> ❑ I affirm that I have power of attorney for: <br /> SIGNATURE <br /> I hereby attest that, to the best of my knowledge, this structure is free from all liens and claims of ownership, except as <br /> show in the attached ownership document application. I further attest that the information on this affidavit is true and <br /> correct. <br /> Kathleen M. Jensen, Trustee Signature: , L '/}1 c; ;ti-\ l' <br /> Print name: � ��' �`�,,v...4-- - <br /> State of r <br /> County of `-Y\-Lb v'(t -- <br /> c-----n <br /> Signed and sworn to (or affirmed)before me on t f (date)by1-A-Cli'GZ <br /> Notary U <br /> (Notary seal) <br /> �t OFFICIAL STAMP <br /> DEPART ENT or = MOLLY BETH HATFIELD <br /> CONUMER <br /> tlUSINESS NOTARY PUBLIC OREGON <br /> I�► SERVICES COMMISSION NO. 957074A <br /> 440-5221 (7/17/COM) MY COMMISSION EXPIRES DECEMBER 13,2020 <br />