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N E <br />DEPARTMENT OF MOTOR VEN1CLES <br />Mobile Igo nc n #1 S 5 <br />Name `J h / hc, <br />Address I a� 1 <br />City, State Zip ( � frit ' 1 nd • ( N <br />m <br />rn LA <br />7 =,. <br />z <br />n <br />Affidavit of Affixture <br />For a Mobile Home With a <br />Nebraska Certificate of Title <br />1 of <br />Affidavit of Affixture For a Mobile Home With a Nebraska Certificate of Title <br />C. J <br />tV <br />Attach additional Affidavit(s) if more than 2 owners. <br />11 Owner of real estate ❑ Leasing real estate <br />Written consent for release of lien and cancellation of Certificate of Title from each lien holder must be attached to this <br />Affidavit. This completed Affidavit must be presented to the County Treasurer along with the Certificate of Title in the <br />county where the real property is located for cancellation of the existing Certificate of Title to occur. <br />A filing fee is required per §33 -109 and §33 -112. <br />Mobile Home Owner #2 A <br />Name k n1 bc � A ; •.J <br />Address 10 4 1 , <br />City, State Zip Grand ts land , <br />Mobile Home Description: Year Make 1 uk , <br />1 ) - 13 - z_ <br />Vehicle Identification Number <br />If two Vehicle Identification Numbers are present, an Affidavit must be completed for each number. <br />Model <br />Title Number"1 k ' <br />Real Est + ' Owner #1 <br />Name lJla,ri E.. w' "v-) <br />Address L W1 I ° ' vL t ( 3 <br />City, State, Zip (.ti` lS ( y;, <br />t�l <br />Real state Owner # <br />Name 4'1l m <br />Attach additional Affidavit(s) if more than 2 entities are to be notified. <br />A <br />Address I [ Cl 1,1 S. <br />City, State, ZipEU 1510 , Nit BEV <br />Copy of Notice of Cancellation shall be provided to all owners listed above and the following financial institution(s): <br />Name <br />Address <br />City, State, Zip <br />Attach additional Affidavit(s) if more than 2 entities are to be notified <br />Name <br />Address <br />City, State, Zip <br />6/2017 <br />