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1-0 115 1 7 TAC c �IC�n 50' MW 1 <br /> NATURE OF FILINGcheck all that applies) <br /> ( pp ) <br /> KA se ]t er t ❑•Change ownership [V9e(n)iit:oi n "Date del itio . <br /> r .c.. g ;' r-, pr...- y er . : . ..__ : u [ Trip permit1 o rte - s age <br /> [ ier: <br /> APPLICANT INFORMATION <br /> ❑ Dealer/seller ❑ Lender [' Escrow/title agent El Owner/buyer ❑ Legal representative <br /> Name:Dennis & Cynthia Bethel <br /> Address (including city, state, and ZIP):3034 Continental SE, Turner, OR 97392 <br /> Phone:503-507-4012 <br /> Email:bethel.cindy@yahoo.com <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 344689 GCC.-(- 3cn <br /> Moving in from another state (Can c,11,-,-.) (DOD.56`;) <br /> Has no home ID or X-plate because: ❑ Coining out of county deed records <br /> PI Other: <br /> Manufacturer: Karsten Homes of Oregon Model: K-103 Year: 2009 <br /> Manufacturer serial number HUD number <br /> STA029571 GRAB-AC ORE 511305 <br /> STA029571 GRAB-AC ORE 511306 <br /> *Number of sections: 2 *Square footage: 1813 *Number of bedrooms: 3 *Number of bathrooms: 2 <br /> *Type of roofing: Comp *Type of siding:Lap *Heating:Heat Pump *Cooling:Heat Pump <br /> *Date of sale: Aui,5" zo zJ *Sales price`.'ZJ� wD, *Includes land: ❑ Yes j No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <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. <br /> Dealer name (print): Dealer signature: Date: <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: (s i,) 3Z7 7 g OS <br /> S <br /> /1o vim, T•C 61-A s f o ci 3-ecc-ecs G � CJ-r 3S <br /> 440-2952(7/19/COM) Page 2 <br />