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aU3c/- &y )or 'Pco' Vt SE, Lyo &s <br /> • NATURE OF FILING (check all that applies) <br /> ❑ Change security interest 0 Change ownership ❑Demolition Date of demolition: <br /> ❑ Recording as real property ❑Removing from real property status 0 Trip permit ❑ Converted to storage <br /> ❑Other: <br /> APPLICANT INFORMATION <br /> 0 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:TANYA.ABADILLA@HOMES.DIRECT <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): L� <br /> NEW b Oo 4c <br /> ❑ Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> H Other: <br /> Manufacturer:PALM HARBOR Model:310HD28443A Year:2022 <br /> Manufacturer serial number HUD number <br /> PHH3100R21-14531A ORE 555384 <br /> PHH3100R21-145318 ORE 555385 <br /> *Number of sections:2 *Square footage: 1188 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:ARCH *Type of siding:FIBER CEM *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:06/04/2021 *Sales price:$106,527.00 *Includes land: ❑Yes El 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 NE <br /> MILLERSBURG MILLERSBURG OREGON 97321 <br /> 541-928-2083 <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 perjur <br /> Dealer name (print): Dealer signatu��'`t` ' ?ef.a. Date: <br /> HOMES DIRECT OF OREGON LLC MILLERSBURG 'b r /� 7� 4G <br /> gresal <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> BENNETT TRUCKING &TRANSPORT 409 BIGHAM BROWN RD <br /> JACKIE YOUNG EAGLE PT OREGON 97524 <br /> 541-879-3444 JACKIE YOUNG <br /> 440-2952(7/19/COM) Page 2 <br />