MANUFACTURED HOME AFFIDAVIT OF AFFIXATION
STATE OF........................)
) SS.
COUNTY OF.......................)
BEFORE ME, the undersigned Notary Public, on this day personally appeared......................... (type the name(s) of each person signing this Affidavit) known to me to be the person(s) whose name(s) is/are subscribed below (each a "Homeowner"), and who, being by me first duly sworn, did each on his or her oath state as follows:
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(Year; Manufacturer's Name; Manufacturer's Serial No(s).)
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(Street or Route; City; County; State; Zip Code)
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Name of Lienholder:........................................
Address:....................................................
Name of Lienholder:........................................
Address:....................................................
[ ] The Home is not covered by a certificate of title. The Home is covered by a Manufacturer's Statement of Origin, issued on the...... of.......... ,..... , manufacturer's serial number........................ , which Homeowner shall surrender to the Secretary of State. A copy of the Manufacturer's Statement of Origin, duly endorsed to Homeowner, is attached to this Affidavit.
[ ] The Home is covered by a certificate of title issued on the....... day of.......... ,...... , title number ........................ , which Homeowner shall surrender to the Secretary of State.
Name:....................................................
Address:................................................
IN WITNESS WHEREOF, Homeowner(s) has/have executed this Affidavit in my presence and in the presence of the undersigned witnesses on this...... day of......, ......
........................... (SEAL)..........................
Homeowner#1 Witness
...........................
Printed Name
........................... (SEAL)..........................
Homeowner#2 Witness
...........................
Printed Name
........................... (SEAL)..........................
Homeowner#3 Witness
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Printed Name
........................... (SEAL)..........................
Homeowner#4 Witness
...........................
Printed Name
STATE OF.........................)
) SS.
COUNTY OF........................)
The foregoing instrument was acknowledged before me this (date) by (name(s) of person(s) who acknowledged).
.......................... Notary Public
Signature
My commission expires:...................
Official Seal:
ATTENTION RECORDER: This instrument covers goods that are or are to become fixtures on the Property described herein and is to be filed for record in the records where conveyances of real estate are recorded.
765 ILCS 170/5-15