AFFIDAVIT IN LIEU OF SURRENDER OF TITLE FOR MANUFACTURED OR MOBILE HOME

EXPLANATION / INSTRUCTIONS

1.This affidavit is authorized by Iowa Code 435.26B and may be used to effectuate a surrender of certificate of title for a manufactured or mobile home if an Iowa title has never been issued or was issued and has been surrendered previously.

2. A preparer (lawyer or agent) may assist with the document and should be noted below.

3. Part J (Execution by Owners) must be notarized. Therefore, this form must be signed as an original by all signatories at each step of the process.

4. When Parts A through H are complete, submit with all required attachments to Iowa DOT with payment of $5.00 as per Administrative Rule 761.400.40(3). For questions regarding this form contact vehicle.recordpolicy@iowadot.us.

Please mail to:Systems and Administration BureauIowa Department of TransportationP.O. Box 9204

OPTIONAL-Complete only if a preparer assisted with the document

E-mail and phone are not required and will only be used for questions about this transaction; this information will not be retained.*

PART A ? OWNER/APPLICANT INFORMATION

E-mail and phone are not required and will only be used for questions about this transaction; this information will not be retainedPlease attach a separate page if necessary for additional owners.

PART B - DESCRIPTION OF MANUFACTURED OR MOBILE HOME (THE "HOME")

PART C-STATEMENT OF OWNERSHIP, LIENS, ENCUMBRANCES OR SECURITY INTERESTS

Attach pages if necessary for additional explanation or statement of liens, encumbrances or security interests.

PART D -FACTS AFFECTING VALIDITY OF TITLE, LIENS, OR ENCUMBRANCES

PART E -RECORD OF PURCHASE / ACQUISITION

PART F -TITLE OPINION

This affidavit requires a written opinion by an attorney licensed to practice law in Iowa who has examined the abstract of title on the land upon which the Home is situated. The opinion states the names of the owners and holders of mortgages, liens or other encumbrances on the land upon which the Home is situated and notes the encumbrances along with any bonds securing the encumbrances. Utility assessments shall not be construed to be encumbrances.

PART G - CITY/ COUNTY ENDORSEMENT OF LOCATION

The Home is located on real property described in the attorney title opinion (Part F) and all the following apply:

The Home is located outside a manufactured home community or mobile home park; andThe Home has been converted to real estate by being placed on a permanent foundation; andThe Home has been entered on the tax rolls

Endorsed by City or County Assessor

PART H - STATEMENT OF TITLE SEARCH BY OWNER(S)

PART I - DEPARTMENT OF TRANSPORTATION ENDORSEMENT AND RECEIPT OF PAYMENT

PART J - EXECUTION BY OWNERS

I (we) the undersigned, being first duly sworn (or affirmed) under oath, state of my (our) personal knowledge that all the preceding information set out in this affidavit is true and correct.

For witnessing or attesting signature:

Signed (or attested) before me on

Official seal

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411186. Affidavit in Lieu of Surrender of Title (Mobile Home)

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