&

Requester: State of Oregon,
Oregon Department of Human Services

Recipient: Carol Hardin

2026-001403

Kiamath County, Oregon

I

2202600014030010017

02/13/2026 11:29:45 AM Fee: $87.00
After recording,
return to: Estate Administration Unit
Attn: Michael W
[J Spouse Oregon Department

of Human Services
P.O. Box 14021
Salem, OR 97309-5024

REQUEST FOR NOTICE OF TRANSFER OR ENCUMBRANCE

This Request for Notice pertains to the following recipient of public assistance, as defined in ORS 411.010:

Recipient's Name: Carol Hardin
Recipient's ODHS Identifier / EAU #: WT101P10 / 608577

This Request for Notice pertains to transfer or encumbrance of the following described parcel of Klamath County real
Lot 4, Block 4, MAZAMA GARDENS, Klamath County, Oregon

property:

Situs Address: 3926 Mazama Dr Klamath Falls OR 97603
Map and Taxlot: 3909-010DD-03000
Tax Account No.: 546902

Pursuant to Oregon Revised Statutes 93.268, 205.246 and 411.694, the Oregon Department of Human Services
requests that notice of transfer or encumbrance of the above described real property, using ODHS Model Form
Notice of Transfer or Encumbrance or a substantially similar form, be mailed to the following address:

Estate Administration Unit Phone: 800-826-5675
Attn: Michael W

Oregon Dept. of Human Services
P.O. Box 14021
Salem, OR 97309-5024

Executed this 10 Day of Felylary ,20 26 .
ORE EPT, OF AN ES (ESTATE ADMINISTRATION UNIT)

-

Name / / Rachelle Ogo N

Title: AS1
STATE OF OREGON, County of _Marion :
The foregoing was acknowledged before me this 10 day of February ,20 26 ‘
by [name:] Rachelle Ogo as [title] AS1 of the Estate

Admijnistration Unit of the Oregon Department of Human Services on its behalf.

O (g

OFFICIAL STAMP
§) Barbara Dawn HamptonReyes
/) NOTARY PUBLIC - OREGON
5 COMMISSION NO. 1053624
MY COMMISSION EXPIRES November 11, 2028

Notary Public for Oregon

My commission expires: / / “/ //902 8

DHS 0522 (Revised 11/19/2020)