Fillable Printable Form 5313 - Affidavit Of Severance

Form 5313 - Affidavit Of Severance

Grantor or Grantee Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Name of Manufactured Homeowner (Person(s) who will be issued Certication of Title)

Residential Address City State Zip

Mailing Address City State Zip

(Space Above Reserved for Recorder of Deeds Certication)

Real Estate Information

Legal Description of Real Estate (Attach a separate exhibit if more space is needed)

Page 1 of 2

Manufactured

Home Information

Manufacturer Name Manufacturer’s Serial Number Home is:

r New r Used

Model Year Make Model Name Dimensions of the Home

Form

5313

Missouri Department of Revenue

Affidavit of Severance

Form 5313 (Revised 06-2014)

Recordation

Information

Date Afdavit of Afxation was Recorded with Recorder of Deeds Book Number Page Number

Obtain from Recorder of Deeds

Reset Form

Print Form

Statement of Facts Regarding Certificate of Title. I hereby state the following: (Place initials in applicable boxes)

The following facts are known by me which affect the validity of the title to the manufactured home

referenced in this application (attach a separate exhibit if more space is needed).

____________________________________________________________________________________

I am not aware of any facts or information that could affect the validity of the title of the manufactured

home or the existence or nonexistence of a security interest in or lien on it.

Statement of Facts

Consent of Affiant

Under the penalties of perjury, I hereby afrm that the aforementioned manufactured home has been severed from the

real estate described in this afdavit. I further afrm that the information contained in this afdavit is true and accurate.

___________________________________________ ___________________________________________

Afant’s Signature Printed or Typed Name of Afant

(Seal)

State of Missouri )

)

County of __________________________)

Subscribed and sworn before me this

___________________ day of _________________________, 20 _____

Notary Signature ___________________________________________

Printed or Typed Name of Notary ______________________________

My Commission Expires ______________________________________

Page 2 of 2

Designated Agent

Designated agent for ling will receive written acknowledgement of compliance.

Name of Designated Agent Business or Agency Name

Street Address City State Zip

Mail to: Motor Vehicle Bureau

P.O. Box 100 Phone: (573) 526-3669

Jefferson City, MO 65105-0100 E-mail: [email protected]

Form 5313 (Revised 06-2014)

Visit http://dor.mo.gov/motorv/homes/

for additional information.

Must be completed by an attorney or licensed agent of a title insurance company.

I certify that the manufactured home described in this Afdavit of Severance is free and clear of, or has been released from, all

recorded security interests, liens, and encumbrances. Place your initials in one of the applicable boxes below:

I certify 1) that the following facts are known to me that could affect the validity of the certicate of title to the manufactured

home described in this application, or 2) that I am aware of the existence of the following lien or encumbrance to the

manufactured home described in this application (attach separate exhibit if more space is needed):

______________________________________________________________________________________________

I am not aware of any facts or information which may affect the validity of the certicate of title to, or the existence of any

lien or encumbrance on the manufactured home described in this application.

______________________________________________________________________________________________

Bar Number if an Attorney __________________ License Number if a Title Insurance Agent __________________

Signature of Attorney or Title Insurance Agent Typed or Printed Name Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

To be completed by an attorney-at-law or agent

of a title insurance company