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• , <br /> r (6.5 8«Ρtan Rcl , VVY1S e e It 0 R 9-73 3 5 <br /> .NATURE OF FILING (check all that applies <br /> c ng e rt C. to st 0 Change ownership ❑ • on Date • eemo <br /> ,( Reco .'ng . re. p [ e qv g rom a ro crtv..tatus 0 Trip permit DkCen'aethastorage <br /> Q 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 /> E <br /> 1�9 60 0 t31 ) <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- a 1 7 ! U A ORE LS 5 (42 47 <br /> F'F 2-1-Do azt-211 [3.8 ORE 5 s (Q ( LE <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:NO.NE <br /> *Date of sale:JULY16,2021 *Sales price:83581.00 *Includes land: ❑Yes 0 No <br /> DEALER INFORMATION (if no.dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> 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,Penalty for perjury <br /> Dealer name (print): V%ea e sig dire., Aar/ Date: <br /> LEISURELAND HOMES INC /Aro7/16/2021 <br /> • TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> SAME AS ABOVE SAME AS ABOVE <br />