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• 4ct\S swcolle QC 44B Sctico-, ct �z �( I <br /> TORE OF FILING (check all that applies) <br /> ITIVAgiAcu4linrgt 0 Change ownership ® (nal e frde th <br /> epdi s al Offerty E o i;oa&rc ai etzy status. 0 Trip permit o r t tor�ge <br /> > APPLICANT INFORMATION <br /> ■❑Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑Legal representative <br /> Name:LEISURELAND HOMES INC <br /> Address(including city; state,and,ZIP): 33964 OAKVILLE RD SW ALBANY OREGON 97321 <br /> Phone: 541-928-1555 <br /> Email: MINDY21M@COMCAST.NET <br /> QHOMEINFORMATION *re aired <br /> Home ID number(f known): DMV X-plate number(if known): <br /> NEW 69004.-17 <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coining out of county deed records <br /> 0 Other: NEW HOME <br /> Manufacturer:FLEETWOOD Model:WINGATE 28543G Year:2021 <br /> Manufacturer serial:number HUD'number <br /> FLE2100R20-21112 A& B ORE554064 <br /> ORE554065 <br /> *Number of sections:2 *Square footage:1440 *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:90,5;65.00 *Includes land: ❑Yes 0 No. <br /> i, DEALERvINFIRMATION (if no d,eailer, leave:blank) ti <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> LEISURELAND HOMES INC MSD119 33964 OAKVILLE RD SW ALBANY <br /> OREGON 97321 <br /> 541-928-1555 <br /> 0 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. ,1 <br /> I hereby declare that the above statement is true to the best of my knpwvledge and belief, and that I understand it is <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name (print): Dealer signatuf e: Date/ <br /> LEISURELAND HOMES INC <br /> • <br /> { <br /> TRANSPORTER INFORMATIONf not moYing, leave blank) <br /> Transporter name: Transp iter address and phone: <br /> LEISURELAND HOMES INC 33964 OAKVILLE RD SW ALBANY OREGON 97321 <br /> 440-2952(7/19/COM) Page 2 <br />