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3 488 U.11 Uc Ln SE . Lyons O -R -735( <br /> .NATURE OF FILING (check all that applies) <br /> ik,e(A110.6hm lest f] Change ownership Me o ' ' n a e • d- •.' 'o r / <br /> Vegacig as " p r ,'Neem tg\fspate,a4- ry�,tati IN Trip permit n rt t r e <br /> I ether: <br /> APPLIC• ANT IN. FORMATION <br /> Q 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): <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 number HUD number <br /> } <br /> PHH 31b OK It' l2 CQ I , ORE 53 p 1 7c <br /> *Number of sections: ` *Square footage: 95'2_ *Number of bedrooms: 7i- *Number of bathrooms: <br /> *Type of roofing: arG(r\ *Type of siding: \.,,a.„15 *Heating: E I.c-F *Cooling:NONE <br /> *Date of sale:311/4 ?,pie) *Sales price: I-16 q ss, d) *Includes land: ❑Yes 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 /> NI/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. n <br /> Dealer name (print): Dealer signature: L2 I had Date: p _1 ,Zr <br /> AjAati jk(A,POile-e6DY\ 1}Y4LOW4 <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 />