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NEB RAS K <br />DEPARTMENT OF MOTOR VEHICLES <br />v1 <br />c; <br />Affidavit of Affixture <br />For a Mobile Home With a <br />Nebraska Certificate of Title <br />ON 1N3Wf1N1SN1 SV 03S31N1 <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 />MobilOome Ow er #1 A <br />Name A)VWY'�\l <br />l� <br />Mobi ome Owner #2 ` 1 <br />Name 0rA r\; \'c \ \ <br />Address Ep3 \i(C4 <br />City, State Zip <br />Attach additional Affidavit(s) if more than 2 owners. <br />Owner of real estate <br />❑ Leasin . real estate <br />Mobile Home Description: Year Agn Make"%rlkl.M. YY T_N 1. 4-61V) _ Model l Lit -73C) <br />Vehicle Identification Number i\ \ C_CQ C)VA Title Number kjc to IQ 3 risk <br />If two Vehicle Identification Numbers are present, an Affidavit must be completed for each number. <br />Real Estate Owner I#1 f <br />Name I� L V V (ne ` I <br />Address <br />P t. D n,eeAr &i (.S L <br />City, State, Zip v °r d- YAW- KL (I 1 <br />Real Es�te�Own�2 <br />Name tt11��11 ►► �I <br />actI <br />Address 2/Q)3 4' l frtr-A rd . <br />City, State, Zip 60.4/4 J it i r u l0 A" <br />Attach additional Affidavit(s) if more than 2 entities are to be notified. <br />Copy of Notice of Cancellation shall be provided to all owners listed above and the following financial institution(s): <br />Name Name <br />Address Address <br />City, State, Zip City, State, Zip <br />Attach additional Affidavit(s) if more than 2 entities are to be notified <br />1 of 3 <br />Affidavit of Affixture For a Mobile Home With a Nebraska Certificate of Title <br />6/2017 <br />1 <br />