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Harold A. Lauritsen ~ AG182001 State of Oregon Department of Consumer and Business Services Building Codes Division 1535 Edgewater St NW Mailing Address: PO Box 14470 Salem,OR 97309-0404 (503)378-4530,FAX(503)378-4101,TTY(503)373-1358 Web:mhods.oregon.gov Email:mhods.bcd@oregon.gov Manufactured Structure Ownership Document Certificates of title are no longer issued for manufactured homes. This ownership document reflects all owners and security interests recorded as of the print date listed below. For the most current recording status, please check the website mhods.oregon.gov or call the Department of Consumer and Business Services at(503) 378-4530. Home Information Manufacturer. SKYLINE HOMES Dwelling Type: Manufactured Dwelling Manufacture Year _ _2089 — __ _Model: WEST RIDGE PREMIER 120OCT Date of Sale: 06/13/2018 Purchase Price: $50,000 Includes Land: No Square Footage: 1232 No. of Bedrooms: 3 No. of Bathrooms: 2 Roofing Material: Composition Heating Type: Electric Siding Type: Lap cement composition Cooling Type: Central Air Conditioner Section Information Serial Number HUD Number 1 BZ91-0191-Y-B ORE 513348 2 BZ91-0191-Y-A ORE 513349 Site Information 17100 SW LASICH LN County: Washington SHERWOOD,OR 97140 Right of Survivorship: No Owner Owner Type TIGARD,CITY OF Business 13125 SW HALL BLVD TIGARD, OR 97223 CITY OF TIGARD, OREGON 228940 Vendor: Harold A Lauritsen Check Date: 06/28/2018 Vendor No. V004159 Vendor Account No: Check Amount: 50,000.00 Invoice Number Date Description Invoice Amount 349042 6/25/2018 Mfg ID no BZ91-0191-Y-A&Y-B 50,000.00 WLCKS5111C WESTERN BUSINESS FORMS&SUPPLIES 36a-667-8203 PRINTED IN U.S.A. City of Tigard JUN 25 2018 Limited Check Request Y Requestor- Steve Martin Division/1-7-nit Code: 6150 Request Date: 6/25/2018 Date Check is Required: 6/27/2018 Note: All requests are due to the Accounts Payable Office no later than Friday by 5 p.m. for checks run the following Wednesday.The printed check will be sent to the vendor the week it is run or back to the requesting department. Make Check Payable To: Harold Lauritsen Street Address:8801 Peach Ave. City: California City State: CA Zip: 93505 Reason for Request- 7 - Employee Reimbursement ❑ -Travel Per Diem or Advance ❑ -Utility Payment ❑ -Petty Cash Reimbursement ❑ - Insurance Payment ❑ -Refund,Tax,Lien, Etc. ❑ - Organizational Dues ❑ -Seminar/Conference Registration ® - Other: This is full payment for a modular building that is currently residing on the Lasich property. The building is in place on a permanent foundation,with all utilities hooked Q.but has a separate owner from the property.This purchase was approved by Council at their June 12,2018 meeting. The purchase of this building will be recorded at Washington County. Details— Description Total$ A ccoLmt Sir , Purchase Modular Home $50,000 420-8000-56005-92034-100 Authorization - Division Staff(Less than$5,000): Division Manager (Less than$12,500): Department Head/Designee (Less than $25,000): City Manager/Designee (Unlimited with conditions):' ' 'l �.� o F Manufactured Structure Ownership Document ,� rb State of Oregon � Department of Consumer&Business Services Building Codes Division 1535 Edgewater NW,PO Box 14460 �;gt Salem,OR 97309-0404 (503)373-1309,Fax(503)378-4101,TTY(503)373-1358 Home Information 349042 Print Date/Time: Manufacturer: SKYLINE HOMES 05/05/2010 10:05 pm Model: WEST RIDGE PREMIER 120OCT Manufacture Year: 2009 Date of Sale: 02/03/2010 Purchase Price: $50,433 Includes Land: NO Square Footage: 1,232 No. of Bathrooms: 2 No.of Bedrooms: 3 Roofing Material: COMPOSITION Siding Type: LAY CFA*2'T C:OMpO.Sl'TION Heating Type: ELECTRIC Cooling Type: NONE Section Manufacturer.0 Number -HUD Number Information BZ91-0191-Y-A ORE 5.11349 BZ91-0191-Y B 'ORE 513348 Site 17100 SW LASiCH LN Information SHERWOOD,OR 97140 WASHINGTON COUNTY Owner Owner Names. Owner Contact Address: Information LAURITSEN,HAROLD A 17100 5W LASICH LN SHERWOOD,OR 97140 Security FIRST NATIONAL BANK OF Interests NOKOMIS 122 W STATE - Perfection Date/rime: 05/04/201012:00 am NOKOMIS,IL 62075 Please note that the buyer and seller are responsible for resolving all other liens and interests recorded with the county or other foreign jurisdictions prior to the sale of the property. These liens and interests are not listed on the ownership document. DE O `Issued under the authority of the Director of the Department of Consumer and Business Services. 9 NO f f iB I SRLrE _ u_ CF �� cs, - , _ - q--Y Z9 a LIT i hoc lz } i � I ; i d i te . i o. I -C Elm IICSoll 7/1/17 TO 6/30/18 MFD STR-P PROPERTY TAX STATEMENT WASHINGTON COUNTY OREGON * 155 N FIRST AVE., RM 130 * HILLSBORO, OREGON 97124 PROPERTY DESCRIPTION MAP: 2S118-00601 ACCOUNT NO: M2170166 SITUS: 17100 SW LASICH LN 2017-2018 CURRENT TAX BY DISTRICT: LAURITSEN, HAROLD A COLLEGE-PORTLAND COMMUNITY 10.89 17100 SW LASICH LN ESD-NW REGIONAL 5.93 SHERWOOD, OR 97140 SCH-TIGARD/TUALATIN 192.18 SCH-TIGARD TUALATIN-LOL AFTER 0.00 LEGAL DESCRIPTION CODE AREA: 023.04 EDUCATION TAXES: $209.00 MFD STRUCT SERIAL # BZ91-0191-Y AIB, Home ID WASHINGTON COUNTY 93.98 349042 ON REAL ACCT 2S118-009..01, PERSONAL MS PORT-PORTLAND 2.93 FIRE-TV FIRE & RESCUE 63.75 AQUATIC-TIGARD TUALATIN 3.76 FIRE-TV FIRE & RESCUE-AFTER 1 18.81 VALUES: LAST YEAR THIS YEAR WASHINGTON COUNTY LOL AFTER 1 26.75 SWC-TUALATI N 3.26 MARKET VALUES: FEE-MFD DWELLING 10.00 LAND GENERAL GOVERNMENT TAXES: $223.24 MFD STRUCT 43,330 41,800 TOTAL RMV VALUE: 43,330 41,800 BOND-SCH-TIGARD TUALATIN-AFTE 74.24 TAXABLE VALUES: BOND-TV FIRE & RESCUE AFTER 4,28 ASSESSED VALUE 43,330 41,800 BOND-WASHINGTON COUNTY AFTER 2.93 BOND-PCC-AFTER 13.47 BOND AND MISC TAX: $94.92 RROPERTY TAXES: $533.21 $527.16 20 7-18 TAX (Before Discount) $527.16 APPEAL DEADLINE January 2,2018 Value Questions 503-846-8826 Tax Questions 503-846-8801 Business Personal Property Questions 503-846-8838 Dther Questions 503-846-8741 PROPERTY TAX PAYMENT OPTIONS (See back of Statement for payment Instructions.) Due Discount Net Amount Due Pay DELINQUENT TAXES: NO DELINQUENT TAXES DUE rn Full 11/15/17 15.81 $511.35 F/3 11/16/17 7.03 $344.41 (See back for explanation of taxes marked with an asterisk('). 113 11/15/17 NONE $175.72 Delinquent Tax Total is included in payment options to the left.) MAKE PAYABLE TO:Washington County TOTAL (After Discount): inline- hi#ps://ecomm.co.washington.or.us/proper"x $511.35 Pay By Phone:1(888)510-9274 We have moved! - New location: 161 NW Adams Ave, Hillsboro, OR 97124 All Payments Processed Upon Receipt CITY OF TIGARD, OREGON 228988 Vendor: Washington County Check Date: 06/28/2018 Vendor No. V004163 Vendor Account No: Check Amount: 70.00 Invoice Number Date Description Invoice Amount Lauritsen Modul 6/26/2018 H Lauritsen Modular Home Purchase Cty Fees 70.00 WLCK66111C WESTERN BUSINESS FORMS A SUPPLIES 3SM67,3203 PAINTED IN UA A. , ��-�� City of Tigard Limited Check Request Requestor-, Steve Martin Division/Unit Code: 6150 Request Date: 6/26/2018 Date Check is Required: 6/27/2018 Note. All requests are due to the Accounts Payable Office no later than Friday by 5 p.m.. for checks run the following Wednesdaj. The printed check will be sent to the vendor the week it is run or back to the requesting department. Make Check Payable To: Washington County Street Address:155 N First Avenue, Suite 130 MSB City: Hillsboro State: OR Zip: 97124 Reason for Request— F-1 -Employee Reimbursement ❑ -Travel Per Diem or Advance ❑ -Utility Payment ❑ -Petty Cash Reimbursement ❑ - Insurance Payment ❑ -Refund,Tax,Lien, Etc. ❑ - Organizational Dues ❑ -Seminar/Conference Registration ® - Other: This $70.00 fee is for Washington County to receive,record, and then pass to the state the transfer of ownership for the Lauritsen modular being_purchased this month The state requires this documentation on modular and manufactured homes. I will deliver the check in person-along with the documentation-after Wa. Co. makes sure that all the paperwork and documents are correct. Details— Description Tntni$ ,c,:ount String Manufactured home transfer $70.00 420-8000-56005-92034-100 documents Authorization - Division Staff(Less than$5,000):_ Division Manager (Less than$12,500): ' Department Head/Designee (Less than $25,000): n� ME m nn ul)City Manager/Designee (Unlimited with conditions): JUN 26 '2018 JU By WASHINGTON COUNTY ASSESSMENT AND TAXATION TH N[< YOU 06/28/2018 1:37PH 01 000000#9206 CLERK01 tax cert $15.00 MANUF HOMES 1 , $55.00 ITEMS 20 ***TOTAL $70- 00 CHECK $70.00 CHANGE $0.00 7/1/17 TO 6/30/18 MFD STR-P PROPERTY TAX STATEMENT WASHINGTON COUNTY OREGON * 155 N FIRST AVE., RM 130 * HILLSBORO, OREGON 97124 PROPERTY DESCRIPTION MAP: 2S71&00601 ACCOUNT NO: M2170166 iTUS: 17100 SW LASICH LN 2017-2018 CURRENT TAX BY DISTRICT: LAURITSEN, HAROLD A COLLEGE-PORTLAND COMMUNITY 10.89 17100 SW LASICH LN ESD-NW REGIONAL 5.93 SHERWOOD, OR 97140 SCH-TIGARD/TUALATIN 192.18 SCH-TIGARD TUALATIN-LOL AFTER 0.00 LEGAL DESCRIPTION CODE AREA: 023.04 EDUCATION TAXES: $209.00 ' MFD STRUCT SERIAL # BZ91-0191-Y A/B, Home ID WASHINGTON COUNTY 93.98 349042 ON REAL ACCT 2S11E-009-01, PERSONAL MS PORT-PORTLAND 2,93 FIRE-TV FIRE & RESCUE 63.75 AQUATIC-TIGARD TUALATIN 3.76 FIRE-TV FIRE & RESCUE-AFTER 1 18.81 VALUES: LAST YEAR THIS YEAR WASHINGTON COUNTY LOL AFTER 1 26.75 SWC-TUALATIN 3.26 UARKET VALUES: FEE-MFD DWELLING 10.00 -AND GENERAL GOVERNMENT TAXES: $223.24 NFD STRUCT 43,330 41,800 TOTAL RMV VALUE: 43,330 41,800 BOND-SCH-TIGARD TUALATIN-AFTE 74.24 'AXABLE VALUES: BOND-TV FIRE & RESCUE AFTER 4.28 iSSESSED VALUE 43,330 41,800 BOND-WASHINGTON COUNTY AFTER 2.93 BOND-PCC-AFTER 13.47 BOND AND MISC TAX: $94.92 ROPERTY TAXES' $533.21 $527.16 20 7-18 TAX (Before Discount) $527.16 .PPEAL DEADLINE January 2,2018 alue Questions 503-846-8826 ax Questions 503-846-8801 usiness Personal Property Questions 903-846-8838 ether Questions 503-846-8741 PROPERTY TAX PAYMENT OPTIONS (See back of Statement for payment instructions.) Due Discount Net Amount Due Ry DELINQUENT TAXES: NO DELINQUENT TAXES DUE Full 11/15/17 15.81 $511.35 3 11/15/17 7.03 $344.41 (See back for explanation of taxes marked with an asterisk :I11/15/17 NONE $175,72 Delinquent Tax Total is induded in payment options to the left.) MAKE PAYABLE TO:Washington County TOTAL (After Discount): Biline- haps://ecomm.co.washington.or.us/properEytax $511.35 iy By Phone: 1(888)510.9274 We have moved! L y New location: 161 NW Adams Ave, Hillsboro, OR 97124 A." varrrnnr.€c ."Srr. ----A 11--- G..,....r..