2026-003909

Klamath County, Oregon

et S o Oroen DA 0
Department of Human Services
00355851202600039090020024

Recipient: _Jeffrey L. Kirsch 05/04/2026 12:57:57 PM Fee: $92.00
After recording,
return to: Estate Administration Unit

Attn: Jamicka Miller
[ Spouse Oregon Department

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

REQUEST FOR NOTICE OF TRANSFER OR ENCUMBRANCE
1. This Request for Notice pertains to the following recipient of public assistance, as defined in ORS 411.010:

Recipient's Name: Jeffrey L. Kirsch
Recipient's DHS Identifier / EAU #: AF67492F / 612896
2. This Request for Notice pertains to transfer or encumbrance of the following described parcel of Klamath County
real property.
See Exhibit A

Situs Address: 145067 Birchwood Rd., La Pine, OR 97739
Map and Taxlot: 2310-036B0-12500
Tax Account No.: 140127

3. 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 DHS 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: _ Jamicka Miller

Oregon Dept. of Human Services

P.O. Box 14021

Salem, OR 97309-5024

Executed this 29th  Day of April 20 26
ORE STRATION UNIT)

By:
Nam

Title: Administrative Specialist 1
STATE OF OREGON, County of Marion :
The foregoing was acknowledged before me this 2%th day of _April ,20 26
by [name:] Ted Ash as [title]  Administrative Specialist 1 of the Estate

gon Department of Human Services on its behalf.
_ o~ OFFICIAL STAMP
Notary Public fof Oregon | =) Barbara Dawn HamptonReyes

My commission expires: / / - / //2028 NOTARY PUBLIC - OREGON

755 COMMISSION NO. 1053624
MY COMMISSION EXPIRES November 11, 2028

i

EXHIBIT A

Lots 10 and 11 inlalgck 4 Sun Forest Estates, according to the official plat
thereof on file in the office of the County Clerk of Klamath County, Oregon.

SUBJECT TO:
1. Transmission lLine Easement, inciuding the terms and provisions
thereof, '
Dated: September 13, 1951
Recorded: ' October 9, 19561, in volume 250 page 282, Deed records of
Klamath County, oregon
From: . Estelle Bexry aka Estelle M. Berry, a widow
To: the United States of America
2. 777 Easement, including the terms and provisions thereof, T
Dated: : June 23, 1872
Recorded: June 30, 1972, in Volume M72 page 7124, Deed records of
Klamath County, Oregon
From: ’ Jack C. Ecoff
To: United States of America
3. Axrticles of Association of Sun Forest Estates Property Owners,
including the terms and provisions therecf,
Dated: September 7, 1972
Recorded: September 10, 1972, in Volume M72, page 10581, Deed Records
of Klamath County, Oregon
4. Building and Use Restrictions for Sun Forest Estates, including the
terms and provisions thereof,
Dated: May 8, 18572 _
Recorded: September 10, 1872, in Volume M72 page 10585, Deed Records

of Klamath County, Oregon