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<br /> 0 Change security interest , 0 Change ownership0 Demolition Date of demolition:
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<br /> 0 Recording as real property Yel Removing from real property status 0 Trip permit 0 Converted to storage
<br /> 0 Other:
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<br /> D Dealer/seller El Lender 0 Escrow/title agent CI Owner/buyer El Legal representative _
<br /> Name:Petr Anfilofieff
<br /> • .
<br /> Address(including city,state,and ZIP):PO BOX 243 Woodburn, OR 97071
<br /> Phone:503-428-4960
<br /> Email:hoodviewconstruction@gmail.com
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<br /> Home ID number(if known): DMV X-plate number(if known):
<br /> 1-10771 WA S 0'-i'l 6-70
<br /> 111Moving in from another state oh 5" i OS c-B t
<br /> Has no home ID or X-plate because: ' gComing out of county deed records
<br /> E Other:
<br /> Manufacturer:Modullne Industries Inc Model:Ardmore Year:1989
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<br /> 1-10771 WA5044671/044672
<br /> *Number of sections:2 *Square footage:1782 *Number of bedrooms:4 *Number of b.athrooms:2
<br /> , •
<br /> *Type of roofing:Metal *Type of siding:t1-11 *Heating:Electric *Cooling:
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<br /> *Date of sale:2/15/2021 *Sales price:5000 *Includes land: D Yes 0 No
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<br /> Dealer nae: Dealer license number: Dealer address and phone:
<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.
<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): Dealer signature: , Date:
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<br /> Transporter name: Transporter address and phone:
<br /> BENT LEVEL CONSTRUCTION INC PO BOX 95 MOLALLA OR 97038
<br /> (503)650-5883
<br /> 440-2952(7/19/COM) Page 2
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