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r` � 1~, MANUFACTURER'S STATEMENT OF ORIGIN
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TO A MOBILE/MODULAR TRAILER n.
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The undersigned CORPORATION hereby certifies that the new trailer a ° -7:1-:;',.--7; '
..
?4 ' described below, the property of said CORPORATION, has been
• transferred this 2J`.', day of June 3000 on Invoice No. 12`99 4..,,,•,-,
To CITY OF TIGARD
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13125 SW HALL BLVD ;
• 01't.:::": „.
TIGARD OR 97223 •
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Trade Name BLAZER Date of Manufacture 06/2000 Year 2000 •
Model Restroom Serial No. SL1232-BL009603
: Other Data Mobile Width 12' Length 36'
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No. of Wheels 6 Ship Weight Wu --,;6`,,-Wh
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The CORPORATION further certifies that this was the first transfer of
. -- such new Trailer in ordinary trade and commerce. •
BLAZER INDUSTRIES, INC. • "�
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1SHIPPING ADDRESS:
945 Olney St.
• Aumsville,OR 97325 f- • • .
MAILING ADDRESS:
•
f P.O. Box 489
Aumsville,OR 97325-0489 : :_1 4
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Authorized Signature r_
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FIRST ASSIGNMENT
For Value Received,the undersigned hereby transfers this Statement of Origin and the motor vehicle described therein to
Address
and certifies that the vehicle is new and has not been registered in this or any other state;he also warrants the tile of said
motor vehicle at time of delivery,subject to the liens and encumbrances, if any, as set out below:
Amount of Lien Date To Whom Due Address
Dated 19 At
Firm Name(Transferor) By:
Signature
Before me personally appeared who by me being duly sworn upon oath says
that the statements set forth above are true and correct. Subscribed and sworn to before me this
day of 19
Notary Seal: Notary Public
County State of
SECOND ASSIGNMENT
For Value Received,the undersigned hereby transfers this Statement of Origin and the motor vehicle described therein to
Address
and certifies that the vehicle is new and has not been registered in this or any other state;he also warrants the tile of said
motor vehicle at time of delivery, subject to the liens and encumbrances, if any, as set out below:
Amount of Lien Date To Whom Due Address
Dated 19 At
Firm Name(Transferor) By:
Signature
Before me personally appeared who by me being duly sworn upon oath says
that the statements set forth above are true and correct. Subscribed and sworn to before me this
day of 19
Notary Seal: Notary Public
County State of
THIRD ASSIGNMEI
For Value Received,the undersigned hereby transfers this Statement of 0 ��
Address �`!.'S /5 74:02",-, 4.57eve
and certifies that the vehicle is new and has not been registered in this or
motor vehicle at time of delivery, subject to the liens and encumbrances, /7'74���n 4 ' sG+GC
Amount of Lien Date To Whon is )4.e. 0,-#71>7
r#y!n
7c ,LXe X46;/
Dated 19 At I"e`S71/*COO:s 4-/ e
Firmm Name(Transferor) ate,
Before me personally appeared ./4g.4...4 9/ 3 li!�t
that the statements set forth above are true and correct. Subscribed and
day of 19
Notary Seal: Notary Public
County � �