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15� 6v t n 9 , c--Kan -e 6 nev5k(` p <br /> NATURE OF FILING (check all that applies) <br /> ❑ Change security interest 0 Change ownership ❑ Demolition Date of demolition: <br /> ❑ Recording as real,property 0 Removing from real property status g Trip permit ❑ Converted to storage <br /> ❑ Other: <br /> APPLICANT INFORMATION <br /> ❑ Dealer/seller El Lender ❑ Escrow/title agent 0 Owner/buyer ❑ Legal representative <br /> Name: <br /> Address (including city, state, and ZIP): / 5 3�3 1 +V� L , �� �; 9-9-38 <br /> Phone: .51)3 `j 1 0, p�1-S <br /> Email: r �: 3 <br /> HO INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> N/A aI �� S(1 � � 1 � 8 cl <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: 2 *Number of bathrooms: 7 <br /> *Type of roofing: *Type of siding: 'd 11_1_ *Heating: Q ; *Cooling: a` <br /> *Date of sale: a_I _�z„ *Sales price: g5' *Includes land: ❑ Yes 0 No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and pho•e•. <br /> (�_ / <br /> .4)! <br /> F ��j Wok (� / / <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 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 /> - Vic:) <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and,aone <br /> )ear-e334-- 1;1 le y " A- <br /> 1 )t(& C/7 <br /> V?---6153er <br /> 440-2952(7/19/COM) Page 2 <br />