Harris County Appraisal District
Form
21MH
(08/11)
Manufactured Home Affidavit
INSTRUCTIONS: Complete all applicable parts of this form and sign it before a Notary Public or other authorized official. Attach
any available documents which provide supporting evidence. Please complete and submit to Information and Assistance Division,
13013 Northwest Fwy., P. O. Box 922004, Houston, TX. 77292-2004. If you have any questions concerning this form please
contact this office at (713) 957-7800.
Name
Mailing Address (street and number)
City
State
ZIP Code+4
Telephone Number (area code and number)
Check and complete any applicable statement.
I have never owned the manufactured home listed under the above account number. I do not know where the
manufactured home is located nor the name of it owner.
I formerly owned the manufactured home listed under the above account number. I no longer own the manufactured
home because:
Manufactured home was sold
Manufactured home was repossessed
I own the manufactured home listed under the above account number but I have moved it to a different location.
(attach additional pages as needed)
Date Moved
Old Location Address
I solemnly swear or affirm that the information given above is true and correct.
If you checked sold or repossessed please give:
Date Repossessed
Street
Signature
Date
Account Number
Other
Date Sold
Address of New Owner/Lender
City
State
Zip Code
Zip CodeState
City
Street
Zip Code
State
City
Street
Other
Subscribed and sworn to before me, the undersigned authority, this the
day of
.
Notary Public, State of Texas
My Commission Expires:
Name of New Owner/Lender Who Repossessed
New Location Address
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