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gra, Av-e GoLle_s406783 NATURE OF FILING (check all that.applies) ' - ah g. a ter• t E .11.4i a s:,rs;'. 0:t,o i;'.2 D.t olitr s c tv, . . . s.e r 1 'e PI v fl . .1 . •. •i +trip permit OcAelytestorage Vostyul\___ APPLICANT INFORMATION ❑Dealer/seller ❑Lender ❑Escrow/title agent Owner/buyer ❑Legal representative Name:Ray Gulliford and Paula Gulliford Address(including city,state,and ZIP):360 E CENTRAL AVE MILL CITY OR 97346 Phone: Email: HOME INFORMATION (*.required) Home ID number(if known): DMV X-plate number(if known): iJ E\kj b[i'39' ❑Moving in from another state Has no home ID or X-plate because: Coming out of county deed records 0 Other: Manufacturer: CMH Model:BREEZE 2.5 Year: 2021 Manufacturer serial number HUD number ALB040062ORAB *Number of sections: *Square footage:l tic./ *Number of bedrooms: `f *Number of bathrooms: *Type of roofing: �y�� *Type of siding: 1 *Heating: -t *Cooling: ' 47 *Date of sale: //..,)/-2.4) *Sales price: 3.6 *Includes land: Yes is2 No DEALER INFORMATION (if no dealer, leave blank) Dealer name: Dealer license number: Dealer address and phone: CLAYTON HOMES ALBANY,OR DLR #MSD195 1437 CENTURY DRIVE NE Ca #1 b6990 ALBANY OR 97322 (541)967-8555 ❑This manufactured structure is free and clear of all mortgages,deeds of trust,security interests,and liens.I have the legal right to sell this manufactured structure. I hereby declare that the above statement is true to the best of my knowledge and belief,and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Dealer name(print): Dealer 'gnat e: Date: ti 1702D TRANSPORTER.INFORMATION (i _ ot moving, leave blank) - Transporter name: Transporter address and phone: '( l,_3z , 7&Z ast �s btk) Ri 012 q 13S 440-2952(7/19/COM) OR Title Application-10/2019-TitleApp11211 Page 2 004372391-00001