THIS INSTRUMENT PREPARED BY: AFFIDAVIT OF AFFIXATION (MANUFACTURED HOME) STATE OF COUNTY OF ss.: BEFORE ME, the undersigned notary public, on this day personally appeared [type the name(s) of each homeowner signing this affidavit]: known to me (or satisfactorily proven) to be the person(s) whose name(s) is/are subscribed below (each a “homeowner”), and who, being by me first duly sworn, did each by personal oath state as follows: 1. Homeowner(s) owns the manufactured home (“home”) described as follows: New/Used Year Manufacturer's Name Model Name and No. Length/Width Manufacturer's Serial No. 2. The home is or will be located at the following “property address”: Street or Route City County State Zip Code 3. The legal description of the real property where the home is or will be permanently affixed (“land”) is: 4. The homeowner(s) executing below is/are all the legal owner(s) of the real property to which the home has become permanently affixed. 5. The home shall be assessed and taxed as an improvement to the land. 6. (A) All permits required by applicable governmental authorities have been obtained; (B) The foundation system for the home complies with all laws, rules, regulations and codes and manufacturer's specifications applicable to the manufactured home becoming a permanent structure upon the real property; and (C) The wheels and axles have been removed. 7. The home is permanently connected to a septic or sewer system and other utilities such as electricity, water and gas. 8. Check one: A. The manufactured home is covered by a certificate of title that the owner shall surrender to the department; B. The manufactured home is covered by a manufacturer's statement or certificate of origin that the owner shall surrender to the department; or C. The manufactured home is not covered by a certificate of title and the owner of the manufactured home, after diligent search and inquiry, is unable to produce the original manufacturer's certificate of origin for the manufactured home; 9. The home is subject to the following security interests (each, a “security interest”): Name of Lienholder: Name of Lienholder: Address: Address: Original Principal Amount Secured: Original Amount Secured: 10. Other than those disclosed in this affidavit, the homeowner is not aware of: (i) Any other claim, lien or encumbrance affecting the home; (ii) Any facts or information known to the homeowner that could reasonably affect the validity of the homeowner's title to the home or the existence or non-existence of security interests in the home. This affidavit is executed by homeowner(s) pursuant to applicable state law and shall be recorded in the real property records in the county in which the home is located. Further affiant(s) sayeth naught. Homeowner #1 Printed Name Homeowner #2 (If more than one homeowner) Printed Name Homeowner #3 (If more than two homeowners) Printed Name STATE OF COUNTY OF Personally appeared before me, , a notary public in and for the state and county aforesaid, , the within named person(s), with whom I am personally acquainted (or proved to me on the basis of satisfactory evidence), and who acknowledged that such person was the one who executed the foregoing instrument for the purposes therein contained. WITNESS my hand and seal at office, on this day of , 20 . Notary Public My Commission Expires: ATTENTION COUNTY REGISTER OF DEEDS: This instrument covers goods that are or are to become fixtures on or improvements to the property described in this instrument and is to be filed for record in the real estate records.
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