v
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Requester: State of Oregon,
Oregon Department of Human Services

Recipient: Meese, Maria G

After recording,

return to: Estate Administration Unit
Attn: _Angie Moon

[] Spouse Oregon Department

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

2026-004624

Klamath County, Oregon

A

00356676202600046
05/26/2026 12:40:25 PM

'Fee: $87.00

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:

Recipient's ODHS Identifier / EAU #.

Meese, Maria G

LW800MS8S / 612961

2. This Request for Notice pertains to transfer or encumbrance of the following described parcel of Klamath County real

property:

Lot 7, Block 1, PINE GROVE RANCHETTES, in the County of Klamath, Sate of

Oregon.

Situs Address: 11623 Mallory Dr, Klamath Falls OR 97603
Map and Taxlot: 3910-009AC-01700

Tax Account No.: 593218

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 ODHS Model Form
Notice of Transfer or Encumbrance or a substantially similar form, be mailed to the following address:

Estate Administration Unit
Attn: _Angie Moon

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

Executed this 19" Day of May

Phone: (800)826-5675

OREGO

By:
Name: Rachelle Ogo
Title: Administrative Specialist-]

STATE OF OREGON, County of Marion

NISTRATION UNIT)

The foregoing was acknowledged before me this

by [name:] _ Rachelle Ogo

Notary Public for Oreg
My commission expires:

day of May , 20 26
Administrative Specialist 1 of the Estate

f Human Services on its behalf.

DHS 0522 (Revised 11/19/2020)

8% Barbara Dawn HamptonReyes

OFFICIAL STAMP

NOTARY PUBLIC - OREGON
i COMMISSION NO. 1053624
MY COMMISSION EXPIRES November 11, 2028