OR Application to Exempt a Manufactured Structure from Title and Registration 1

X PLATE # _________________ EXEMPT FILE # _______________

INSTRUCTIONS: The following must be submitted to DMV:

1)This form, completed and signed by all parties with an interest in the manufactured structure. All areas of the form must be completed.

2)A Title Report or Lot Book Report. (The title report or lot book report cannot be over 7 days old when submitted to DMV.)

3)If the manufactured structure is new and is financed, proof of the loan approval.

4)Proof all taxes for the current tax year have been paid on the manufactured structure. Proof may be a Certificate of Taxes Paid, Form 113, issued by the county where the manufactured structure was located.

PART I LAND

If there is a mortgage, deed of trust or lien on this land, list all mortgagors, beneficiaries of deeds of trust below. Space is provided for two names and addresses. If there are none, write "none."

Name and AddressLoan Number

___________________________________________ _________________

Name and AddressLoan Number

___________________________________________ _________________

Legal description and location of real property; (as recorded by county recorder or a certified copy of your deed may be substituted)

_______________________________________________________________________

_______________________________________________________________________

Property Address

_______________________________________________________________________

Tax Lot Number (from assessor) Map Number Account Number

__________________________ ____________ _____________________

If there is a mortgage, deed of trust or lien on the manufactured structure, list all security interest holders, mortgagees, beneficiaries of deeds of trust, and lien holders whose interest is secured. Space is provided for two names and addresses. Approval signatures are required. If there are none, write "none."

PART II MANUFACTURED STRUCTURE

Legal description of manufactured structure:

Year Make Width Length Vehicle Identification Number(VIN)

____ ____ _____ _____ _____________________________

Name and AddressApproval Signature

________________________________________ x _____________________

Name and AddressApproval Signature

________________________________________ x _____________________

___ I/We do not know the whereabouts of the permanent plate assigned to this vehicle.

PART III OWNER SIGNATURES AND CERTIFICATIONS

I/We certify that the statements made above are accurate to the best of my/or knowledge. All liens, deeds of trust, mortgages and security interests have been listed. If there are none, I/We have certified this by writing "none" in the space provided.

Printed Name of Owners(s)ODL/ID/Customer #Date of BirthTelephone #

_________________________ _______________ _________ ( ___ ) _______

Printed Name of Owners(s)ODL/ID/Customer # Date of BirthTelephone #

_________________________ _______________ _________ ( ___ ) _______

Residence AddressMailing Address

___________________________________________ _______________________

Signature of OwnerSignature of Owner

x __________________________________________ x ______________________

Office use only PART IV Office use only

Application for exemption for a manufactured structure is hereby approved.

Signature DateSignature of DMV Officer

_____________________ _______________________________________________

This exemption is Void if not recorded with the county by this date:

Expiration Date: ______________________

PART V

Official Recording by County Clerk

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________