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34-BS ) _)'t Uc4. Lin SE . LyOfl5 0 -R ci -73:5( <br /> :NATURE OF. FILING (check all that applies) <br /> ilLefiNiagn05atdest 0 Change ownership e o " n a e d n <br /> t ec• 'I g aNta p Th /1&�m�yi g r r n yo rte taq VI Trip permit [%C n rt t r e <br /> `. ether: <br /> APPLICANT INFORMATION,` <br /> El Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name:HOMES DIRECT OF OREGON LLC MILLERSBURG <br /> Address (including city,state,and ZIP):3838 PALM HARBOR DR MILLERSBURG OR 97321 <br /> Phone:541-928-2083 <br /> Email:MARK.GORMAN@HOMES.DIRECT <br /> HOME INFORMATION'(*required). <br /> Home ID number(if known): DMV X-plate number(if known): 4 <br /> ""-5 ( OM'(03 <br /> n Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ❑ Other: <br /> Manufacturer:PALM HARBOR Model: Year:2021 <br /> Manufacturer serial numbernn HUD number <br /> PHH 31b IC- 12-S/1 ORE $f 7b"7 <br /> *Number of sections: ` *Square footage: q52.... *Number of bedrooms: 2-- *Number of bathrooms: 2__ <br /> *Type of roofmg: ardr\ *Type of siding: La-13 *Heating: E I.c4 *Cooling:NONE <br /> *Date of sale: 30\ ?AA *Sales price: 14(„ l ss db *Includes land: ❑Yes 0 No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> HOMES DIRECT OF OREGON LLC MSD-523 3838 PALM HARBOR DRIVE <br /> MILLERSBURG MILLERSBURG OREGON 97321 <br /> This manufachred 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. n <br /> Dealer name(print): Dealer signature: on t/'I(ir Date: /' —I ,1( <br /> AMA Wk[40ae-6M U-C/ PYINIA8k4%. 14°446 bta-ML,L, <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> BENNETT TRUCKING 409 BIGHAM BROWN ROAD <br /> EAGLE POINT OREGON 97524 <br /> 541-879-3444 JACKIE YOUNG <br /> 440-2952(7/19/COM) Page 2 <br />