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DocuSign Envelope ID:5975253C-EFEF-4E6B-91F5-1440C90B0464 �31'� R I vr_V Rd Iv 6 '4 . ST 'Peat l <br /> NATURE OF FILING (check all that applies) <br /> ❑ Chans,rit3-interestt❑ Change ownership ❑ Dm • •• :. - • •- . <br /> ❑. -_e .•1.I s_ • • ••-•I• ► - •a • g f e,,, «owl praperty status Trlp ait---C—on:verted-tr-storage- <br /> 11 <br /> ( <br /> ❑ Ot•- • <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller n Lender ❑ Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name:Alta Cima Corp dba Factory Expo Home Centers <br /> Address(including city, state, and ZIP):2555 Progress Way, Woodburn, OR 97071 <br /> Phone:503-981-0770 <br /> Email:ccunio.©factoryexpohomes.com <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): ��"" <br /> �EW/ 1o0b09 <br /> ❑ Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ❑ Other: <br /> Manufacturer:Fleetwood Model:Bauman 28403A Year:2022 <br /> Manufacturer serial number HUD number - <br /> FLE2100R21-21675A ORE 556073 <br /> FLE2100R21-21675B ORE 556074 <br /> *Number of sections:2 *Square footage: 1,066 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Comp *Type of siding:Fiber Cement *Heating:Electric *Cooling:None <br /> *Date of sale:7/22/2021 *Sales price:$103,173.77 *Includes land: ❑ Yes ❑No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> Alta Cima Corp dba Factory Expo MSD448 2555 Progress Way <br /> Home Centers Woodburn, OR 97071 <br /> 503-981-0770 <br /> Q 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): ,_Dg1•gature: Date: <br /> Alta Cima Corp aid./ 6/30/2021 <br /> `— <br /> TRANSPORTER INFORMATIBO9N6fCnFo <br /> t moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> Superior Home Transport, LLC P.O. Box 1067 <br /> Jefferson, OR 97352 <br /> 440-2952(7/19/COM) Page 2 <br />