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I. <br /> NATURE OF FILING (check all that applies) <br /> ❑Change security interest Q Change ownership ❑Demolition Date of demolition: <br /> ❑Recording as real property I ❑Removing from real property status I 0 Trip permit I ❑ Converted to storage <br /> El Other: <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller ! ❑Lender ! 0 Escrow/title agent I D Owner/bu er <br /> y I ❑Legal representative <br /> Name: <br /> Address(including city,state, and ZIP): <br /> Phone: <br /> Email: <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): i 9 <br /> �/ . tI-78c, <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: 5 (_,e4..,��5 - l Model: f Year : IC`i 1 <br /> ' r Manufacturer serial number I HUD number <br /> 177U‘S7 g <br /> *Number of sections: , *Square footage: t a61 *Number of bedrooms: <br /> j___ I *Number of bathrooms: <br /> *Type of roofing: I *Type of siding: — I - I, ng: I <br /> E�i I *HeatiJ <br /> � - rI e_G'7'i l Cooling: �115),____* <br /> *Date of sale: 17._—).2.--..2.-e.>: I <br /> s *Sales price: J *Includes land: <br /> ❑Yes ®No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: ' Dealer license number: Dealer address and phone: <br /> Dougs mobile home service inc 652 12692 Fry rd ne Aurora OR 97002 <br /> 0 This manufactured structure is free and clear of all mortgages, deeds of trust, security interests,and liens.I have the <br /> Iegal 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(print): 1 Dealer si e: Date: <br /> Doug Walton <br /> cam , <br /> TRANSPORTER INFORMATION (if not moving, leave blank) • <br /> Transporter name: Transporter address and phone: <br /> Dougs mobile home service inc 12692 Fry rd ne Aurora <br /> 440-2952(7/79/COM) <br /> Page 2 <br /> 6'd 6621•-002-£09 aolnaag ewoH allgow s6noa d6Z Z0'OZ 0£• <br />