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�5% R ;- -k \kOv n9 , Cor8 -e O ne`5kip <br /> NATURE OF FILING (check all that applies) <br /> ❑ Change security interest ■❑ Change ownership ❑ Demolition Date of demolition: <br /> ❑ Recording as real,property 0 Removing from real property status cz Trip permit ❑ Converted to storage <br /> ❑ Other: <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller ❑Lender ❑Escrow/title agent 0 Owner/buyer ❑ Legal representative <br /> Name: (fes 3 1� <br /> Address (including city, state, and ZIP): 1 5 34,13 14.+V> t L , �� ;f trp.._ 9-93 <br /> Phone: .503 <br /> Email: <br /> HO INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> N/A al � 5 I � � ce <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ❑ Other: <br /> Manufacturer: Silvercrest Model: Year: 1991 <br /> Manufacturer serial number HUD number <br /> 17706578 <br /> *Number of sections: 2 *Square footage: 1296 *Number of bedrooms: ,7 *Number of bathrooms: 7 <br /> *Type of roofmg: *Type of siding: 1_1_1 *Heating: *Cooling: <br /> *Date of sale: 1 a _;a _aZL *Sales price: 0 *Includes land: ❑ Yes ❑No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and pho e• <br /> A. { 44- <br /> viGam Gbhte.-- Uses 9 7,e,w — <br /> KfThis 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 knowledge 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 - Dealer sign. - Date: <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and tone <br /> ,/ - v - C/7x . <br /> \co -het <br /> 440-2952(7/19/COM) Page 2 <br />