STATE OF SOUTH CAROLINA COUNTY OF BEAUFORT ) ) ) MANUFACTURED HOME LIEN AFFIDAVIT 1) Name of Owner(s)___________________________________________________________________________ 2) Description of Manufactured Home: Date of Manufacture: ____________ Manufacturer: ________________________________________ Model Year: _____________ Make: ____________________________________________________ Width: ____________ Length: ___________________ Identification Number (VIN): __________________________________ 3) The above described manufactured home is subject to a security lien and all secured parties with mailing addresses are listed below: _____________________________________________________________________________ 4) Full legal description of new property to which manufactured home 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.) 5) Derivation: This being the identical or a portion of property conveyed or leased to the owner by deed or lease from _____________________________________________________________________ and recorded on _____________ in Book _________ at Page ______________. Tax Map number: ________ ____ ___________ ____________ ____________ Tax Billing Address: ____________________________________________________ ____________________________________________________ 6) Name of owner of real property if different from owner of manufactured home: __________________________________________________________________ 7) The owner of the manufactured home affidavit was recorded on ___________________ in Book ____________ at Page _____________ in the county of Beaufort. 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 ___________________________________________ Owner's Typed/Printed Name Witness: ________________________________________ Witness: ________________________________________ STATE OF SOUTH CAROLINA COUNTY OF BEAUFORT ) ) PROBATE Before me, the undersigned Notary Public, personally appeared ______________________________________ who, being duly sworn, deposed and said that he/she saw ______________________________________________ sign, seal and deliver the foregoing affidavit and that he/she, together with _________________________________ witnessed the execution thereof. Sworn to before me this _________ day of _______________, 20__ Notary Public for _____________________________(LS) My Commission Expires: ______________________ American LegalNet, Inc. www.FormsWorkflow.com