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C-octet, , G 1 34 <br /> NATURE OF FILING (check all that applies) <br /> ❑ Change security interest t❑ Change ownership ❑Demolition Date of demolition: <br /> ❑Recording as real property ❑Removing from real property status 11 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): <br /> NEW en O04(0(0 <br /> n Moving in from another state (5-Cr 5b;S-) <br /> Has no home ID or X-plate because: I I Coming out of county deed records <br /> ❑ Other: <br /> Manufacturer:PALM HARBOR Model:3104G28563B Year:2021 <br /> Manufacturer serial number HUD number <br /> PHH3100R21-14526A ORE 555376 <br /> PHH310OR21-14526E ORE 555377 <br /> *Number of sections:2 *Square'footage: 1620 *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:05/25/2021 *Sales price:$128,941.00 *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 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 perjury. �d <br /> Dealer name (print): Dealer sigpaatu : Date: <br /> HOMES DIRECT OF OREGON LLC MILLERSBURG VI YJYt OY(eC.T�� 7l S0` <br /> V! <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 />