2 /o —~ VE (- 1C 2, Afier recording retrn to: AmeriTitle (For € 2026-004267 404 Main St. Ste 1 Klamath Falls. OR 97601 Klamath County, Oregon 05/14/2026 02:01:01 PM Send all future tax bills to- Fee: $92.00 Jason Horn and Nicole Horn PO Box 244 Chiloguin, OR 97624 APPLICATION FOR RECORDING MANUFACTURED HOME AS REAL PROPERTY Check appropriate box; 8 New home o Existing home - X Plate Number (il applicable) LEGAL DESCRIPTION OF MANUFACTURED STRUCTURE ?YlaAR MA KE HUD %L‘E\'I?Eill - LYI\RH]CIJEJ&H),EN1&(EAEION NUMBER (VIN) )’VI‘DII‘L{ __LENGTH 20700 [CANCO é WL m)’EQ ENERT e et Ldet HOME ID COUNTY ID NUMBER | SITUS ADDRESS N/A 209125, 209134 8425 Whitehorse Way Chiloquin, QR 97624 Legal description per ORS 93.600 or reference number of previously recorded deed. (Attach additional sheets, if needed.} Map and tax lot number: 3408-022C0-02200, 3408-022C0-02300; Lots 11 and 12 in Block 6, First Addition to Sprague River Pines, according to the official plat thereof on file in the office of the County Clerk of Klamath County, Oregen PRINTED NAME OF OWNER(S} Jason Gerard Horn PRINTED NAME OF OWNER(S) (For additional owners, attach a second sheet) Nicole Yvonne Horn MAILING ADDRESS (1{ different (han situs address) PO Box 244 Chiloguin, OR 97624 SECURITY INTEREST HOLDER NAME AND ADDRESS (1f no security interest holder, write “none.” Attach additional sheet if needed.) Evergreen Moneysource Mortgage Company 1427 Energy Park Dr. Saint Paul, MN 55108 b@\ ACKNOWLEDGEMENT \ 1212025 (‘ounty assessor/tax collectlor or escrow officer Date CERTIFICATION [ certify that, according to ORS 446.626: + The same person owns the manufactured structure and the real property as described above on which the manufactured structure is or will be situated QR + The owner of the manufactured structure holds a recorded leasehold estate of 20 or more years of the land; ¢ The manufactured structure is or will be affixed to the real property and subject to taxation by the county in which it is located as an improvement to the real property; + Each person with a security interest in the manufactured structure and each person with a security interest in the real property approves the exemption from ownership document; and + This certification is being submitted for recording to the county clerk for the county in which the real property is located. A copy of said recorded document is being provided 1o the county assessor in addition 1o the State of Oregon Building Codes Division, or one of its county agents along with the County Manufactured Home Notification and Tax Certification Form for Used Homes and a Manufactured Home Bill of Sale/Change Application. X SIGNATURE OF OWNER\_ Ju A X SIGNATURE OF OWNER bt . State of Oregon. County of'_K!?MZ N The foregoing ingtrument was acknowledged bef?re mc this JLP day of bc by Jaso Cae v d %ggg\co\c 'L/W Horn Signature of notary public:. My commission expires: 19" 5()202??’ 13 OFFICIAL STAMP S ~’,~ JULIE MARIE VANLEUVEN §15) NOTARY PUBLIC-OREGON COMMISSION NO. 1042200 MYICRNMISSIGHENRPIRES OCTOBER 30, 2027 /140 5176 {12/24/COM} Page | 1 MANUFACTURER'S STATEMENT OR CERTIFICATE OF ORIGIN TO A MANUFACTURED HOME Manufacturer: Cavco Manufacturing, LLC : Cavco Millersburg Address: 3737 Palm Harbor Drive, Millersburg, OR 97321 Streer. Cire. State. and Zip The undersigned MANUFACTURER hereby certifies that the new manufactured home described below. the property of said MANUFACTURER, has been transferred This_18th _ day of _March . 2026 2025106678700 on Invoice To: _Palm Harbor Villages #267 Distributor, Dealer, Etc. FIRST ASSIGNMENT For Value Received, the undersigned hereby transfers this Statement of Origin and the manufactured home described therein to: Address and cenifies that the home is new and has not been registered in this or any other state; he also warrants the title of said home a1 time of delivery. subject to the [iens and encumbrances, if any. as set out below Amt. Of Lien Date Fo Whom Due Address Dated . al By: Transferor (Firm Nante) Sign Here Dealer License {Pernif) No. Before me personally appeared duly sworn upon oath says that the statements set forth above are true and correct. Subscribed and sworn to before me this day of Notary Public for Position who by me being County, State of Notarv Seal SECOND ASSIGNMENT For Value Received. the undersigned hereby transfers this Statement of Origin and the manufactured home described therein to: Address and certifies that the home 1s new and has not been registered in this or any other state; he also warrants the title of said home at time of delivery, subject to the liens and encumbrances, if any, as set out below Amt. Of Lien Date To Whom Due Address Dated . at By Trangferor (Firm Name) Sign Here Position Dealer License (Permit) Ne. Before me personally appeared duly sworn upon oath says that (he statements set forth above are true and correct. Subscribed and swomn to before me (his day of Notary Public for who by me being County, State of Whose Address 320 Pear Tree Lane Street Medford OR 97504 Ciry. Stare. and Zip Series: _400 Model Year:_ 2026 Model No: _3104G28563B Body Width Ft: 27 ¢ Body Length Ft: 60' 0" /Ft: 56' 0" Including Hitch Excluding Hitek Square Feet; 1445 Date of Manufacture: 03/13/2026 Manufacturer's ID No: CAV3I100R25-16813A Weight 25,992 Manufacturer's ID No: CAV3100R25-16813B Weight 25,164 Manufacturer's ID No: Weight Manufacturer's ID No: Weight Manufacturer's ID No: Weight Manufacturer's ID No: Weight The CORPORATION further Certifies that this was the first transfer of such new manufactured home in ordinary trade and commerce. Cavco Manufactyriag;LLC : Cavco Millerébirg By<—_ — Sign Name 3737 Palm Harbor Drive, Millersburg, OR 97321 Office Addre: Title or b.un..:zc: of Signatery (City & Sratel Notary Seal THIRD ASSIGNMENT For Value Received, the undersigned hereby transfers this Statement of Origin and the manufactured home described therein to: Address and centifies that the home is new and has not been registered in this or any other state; he also warrants the title of said home at time of delivery, subject to the liens and encumbrances, if any, as set out below Amt. Of Lien Date To Whom Due Address Dated y al PN A o Transferor (Firm Name)} Sigm Here Dealer License (Permit) No. Before me personally appeared duly sworn upon oath says that the stalernents set forth above are true and cotrect. Subscribed and sworn 10 before me this day of . Notary Public for County, State of Position who by me being Notary Seal Form Revision Date: 1141052623