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CASH <br />CHECK 21s A4 <br />0 <br />IVY <br />co <br />co s1:u: <br />NEE .:14iA <br />DEPARTMENT OF MOTOR VEHICLES <br />REFUNDS: <br />CASH <br />CHECK <br />.fit l ) ED <br />T HALL <br />CO . 1 NE <br />U Y O 7O A?i d w c P 4: 18 <br />DEEDS <br />2 00 <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 />Mobile Home Owner #1 <br />Name Andrew J. Woitaszewski <br />Address 7337 Blender Rd <br />City, State Zip Grand Island, NE 68803 <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 <br />❑ Leasing real estate <br />Mobile Home Description: Year 2002 Make Genesis Model NB <br />Vehicle Identification Number 470210304276AB <br />Title Number <br />If two Vehicle Identification Numbers are present, an Affidavit must be completed for each number. <br />Real Estate Owner #1 <br />Name Andrew Woitaszewski <br />Address 7337 Blender Rd <br />City, State, zip Grand Island, NE 68803 <br />Real Estate Owner #2 <br />Name Adam Woitaszewski <br />Address <br />7337 Blender Rd <br />City, State, Zip Grand Island, NE 68803 <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 />