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• <br /> . L 'O w c1C,r • r r ) f `N t . ) . 10 r <br /> I. 'NATURE OF FILINGGcheck all that applies) <br /> a e s r nte[�:b' �� i 15\, D i i a o. -m• i g n: - <br /> �� e,or•' g: ea op, y •e .. 1 n 1 . 6.,d s t Q Trip.permit tj,k, -. -. o e age <br /> Hier: <br /> (APPLICANT INFORMATION <br /> ❑Dealer/seller ❑ Lender ❑Escrow/title agent ❑ Owner/buyer 0 Legal representative <br /> Name:LEISURELAND HOMES INC <br /> Address (including city, state, and ZIP):33964 OAKVILLE RD SW, ALBANY OR 97321 <br /> Phone:541-928-1555 <br /> Email: MINDY21 M@COMCAST.NET <br /> HOME INFORMATION (*required) <br /> I-Iome ID number(if known): DMV X-plate number(if/noun): <br /> NEW HOME 3 0 639 <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coining out of county deed records <br /> 11 Other: NEW HOME <br /> Manufacturer: FLEETWOOD WAVERLY Model: 28563L Year:2021 <br /> Manufacturer serial number HUD number <br /> FLE210OR20-2122721 A& B ORE55434 D <br /> ORE554341 <br /> 11 <br /> *Number of sections: 2 `: *Square footage: 1492 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing: ARCH *Type of siding: CEMENT *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:12/8/2020 *Sales price:94,387.00 *Includes land: ❑ Yes 0 No <br /> DEALER INFORMATION (if no dealer, leave"blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> LEISURELAND HOMES INC MSD119 33964 OAKVILLE RD SW <br /> ALBANY OREGON 97321 <br /> *This manufactured structure is free and clear of all mortgages, deeds of trust,security interests,and liens. I have the <br /> legal right to sell this manufactured structure. <br /> I hereby declare that the-above statement is true to the best of my l5tbwledge and belief,and that I understand it is <br /> made for use as evidence in court and is subject to penalty for pei y y. <br /> Dealer name(print): Dealer signature : Date: / <br /> LEISURELAND HOMES INC <br /> L./ • - �LJ Z <br /> TRANSPORTER %NFORMATIO1 -(if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> LEISURELAND HOMES lNC 33964 OAKVILLE RD SW <br /> ALBANY OREGON 97321 <br /> 440-2952(7/19/COM) Page 2 <br />