STATE OF SOUTH CAROLINA ) ) COUNTY OF BEAUFORT ) MANUFACTURED HOME AFFIDAVIT FOR RETIREMENT OF TITLE CERTIFICATE (1) Name of Owner:______________________________ (2) Description of Manufactured Home: Date of Manufacture: ________________________ Manufacturer: ____________________________ Model year: _____________ Make: ____________________________________ Width: ________ Length: _______________ Identification Number (VIN): __________________ (3) Check whichever is applicable: _____The above described manufactured home is not subject to a security lien. _____The above described manufactured home is subject to a security lien and a separate affidavit, as required by law, will be filed naming the secured parties. (4) Check whichever is applicable: _____The above described manufactured home is located in a jurisdiction with locally enforced building and safety codes adopted pursuant to Title 6, Chapter 9 and attached to this form is written evidence of compliance with the applicable codes as of the date the manufactured home was permanently affixed to the above described real property. Written evidence of compliance includes, but is not limited to, a copy of a certificate of occupancy, a statement from the code enforcement office, an inspection report, or any documentation of similar effect from the local code enforcement office having the appropriate jurisdiction. Only one document should be attached to this form. _____The above described manufactured home is not located in a jurisdiction with locally enforced building and safety codes adopted pursuant to Title 6, Chapter 9 applicable to manufactured homes. (5) Full legal description of the property to which the manufactured home is currently, or is to be, affixed using metes and bounds or reference to recorded plat by book and page. (A separate sheet identified as ‘Exhibit A’ may be attached.) (6) Derivation: This being the identical or a portion of property conveyed or leased to the owner by deed or lease from _______________________________ and recorded ____________ in Book _______ at page ________. Tax map number ________________________ Tax billing address ______________________ (7) The above-described manufactured home is permanently affixed or is to be permanently affixed to the above-described real property and the title certificate is to be retired in accordance with applicable law. (8) Check if applicable: ______The owner of the manufactured home owns or has a leasehold estate of thirty-five or more years in the real property to which the manufactured home is affixed. (9) WARNING: the execution and filing of this affidavit transfers ownership of the manufactured home to the lawful owner of the real property to which it is affixed. The owner certifies that the above information provided by the owner is true and correct to the best information and belief of the owner. Date: ___________ Signature of owner: ________________________________ Type or print name of owner: _______________________________ Witness: _____________________________ Witness: _____________________________ STATE OF SOUTH CAROLINA ) COUNTY OF ________________ ) PROBATE Before me, the undersigned Notary Public, personally appeared ______________________________, who, being duly sworn, deposed and said that (s)he saw ___________________________________, sign, seal, and deliver the foregoing Affidavit and that (s)he, together with ____________________________ witnessed the execution thereof. SWORN to before me this ___ day of _______________ , 20__ Notary Public for_________________(L.S.) My Commission Expires:_____________ American LegalNet, Inc. www.FormsWorkflow.com