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°118 5 ton Ra) I, o R 9-13 3 5 <br /> NATURE OF FILING (check all that applies) - <br /> 0,,g1Qvia(ritikinqest # Change ownership ❑ on ate emo : <br /> lEtzeco .'ng . r. p • [aFit v' g rom ro erly_st)tus Trip permit DCer ve torage <br /> Other: <br /> APPLICANT INFORMATION <br /> Dealer/seller ❑Lender ❑ Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name:LEISURELAND HOMES INC. <br /> Address(including city,state,and ZIP):33964 OAKVILLE RD SW ALBANY OR 97321 <br /> Phone:541-928-1555 <br /> Email:LEISURELANDHOMES@GMAIL.COM <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ®❑ Other:NEW HOME/FACTORY ORDER . <br /> Manufacturer:FLEETWOOD Model:28523P Year:2022 <br /> Manufacturer serial number HUD number <br /> FLE2100R21- � 7 16 A ORE &Z lQ I 7a <br /> FF2Lb0a2.(-21 egg ORE 5� <br /> *Number of sections:2 *Square footage:1333 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:ARCH *Type of siding:CEMENT *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:JULY16,2021 *Sales price:83581.00 *Includes land: ❑Yes El No <br /> DEALER INFORMATION (if no,dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> LEISURELAND HOMES INC. MSD119 33964 OAKVILLE RD SW <br /> ALBANY OR 97321 <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 enalty for perjury <br /> Dealer name(print): ea a•sig fure•; Date: <br /> LEISURELAND HOMES INC e Arr riorr7/16/2021 <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> SAME AS ABOVE SAME AS ABOVE <br />