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1349979 • 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/current owner name(print) Seller/current owner signature: Date: ❑1 release my interest in this structure. CLAYTON HOMES ALBANY, \l,KVA.434(W ORjiPhone:(541)967-8555 19115 ❑1 acknowledge this sale/change of ownership, Entail: but do not release my interest in the structure. Seller/current owner name(print) Seller/current owner signature: Date: ❑I release my interest in this structure. Phone: 0 I acknowledge this sale/change of ownership, Email: but do not release my interest in the structure. Seller/current owner name(print) Seller/eurrent owner signature: Date: 0 I release my interest in this structure. - Phone: []I acknowledge this sale/change of ownership, Email: but do not release my interest in the structure. Seller/current owner name(print) Seller/entreat owner signature: Date: ❑I release my interest In this structure. Phone: 0 I acknowledge this sale/change of ownership, Email: but do not release my interest in the structure• SECURITY INTEREST HOLDER ALREADY ON RECORD(If applicable) Security holder's name(print) Security holder's signature: Date: ❑I release my interest in this structure. (J I acknowledge this sale/change of ownership, but do not release my interest in the structure. Security holder's name(print) Security holder's signature:. Date: ❑1 release my interest in this structure. l acknowledge this sale/change 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 otvners/buyers,and security interest holders). E]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). [l If this application is being submitted by the seller,you must also submit a bill of sale. • 440-2952(7/17/COM) OR Title Application•1012018-TitleAppl 1211 Page 5 004186486-00001