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Z0ZI0ZZ0Z <br />N E RAK r <br />DEPARTMENT OF MOTOR VEHICLES <br />Affidavit of Affixture <br />For a Mobile Home With a <br />Nebraska Certificate of Title <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 />Mobi ome/�O�wnrer� #1 <br />Name �,� Valet() let() 1 ct V l--1- i <br />Address -I 1 rJ L. + <br />City, State Zip -6 \I /Jo ( V L& A`) <br />Mobile Home Owner #2 <br />Name <br />Address <br />City, State Zip <br />Attach additional Affidavit(s) if more than 2 owners. <br />Owner of real estate ❑ Leasing real estate <br />Mobile Home Description: Year <br />_____Make YAV (6f1 <br />Model ' <br />Vehicle Identification Number 2) Title Number vuDub2 3-720 <br />If two Vehicle Identification Numbers are present, an Affidavit must be completed for each number. <br />Real Esf ate Owner #1, <br />OA Y <br />Name l t V14- <br />Address 1 tp E <br />City, State, VA ILLCV (lj L`JVJ <br />Real Estate Owner #2 <br />Name <br />Address <br />City, State, Zip <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 <br />Address <br />City, State, Zip <br />Name <br />Address <br />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 />