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I D53 q ccaban Ln . E , ' ctAe_v.N-) Q -73°3 <br /> NATURE OF FILING (check all that applies) <br /> se ui• ' 61st 121 Change ownership MOOtilOthiotilli&rtadratian <br /> i1 c.t gi aa% aj rtt✓0.11at o g wrn repe ®Trip permit tcrCavArj.edilksylge <br /> R er: <br /> APPLICANT INFORMATION <br /> ❑ Dealer/seller ❑Lender ❑Escrow/title agent tC Owner/buyer ❑ Legal representative <br /> Name: Ripe)ems' A . A w • <br /> Address(including city,state,and ZIP): 10 5 cc' LAI N . sac,., 04 413 6 4 <br /> Phone: £03 - V3 • ' 7,2,2. <br /> Email: d e.r F 404.o+0 q „).Lad's► <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 0 Moving in from another state <br /> Has no home ID or X-plate because: El Coming out of county deed records <br /> 0 Other: <br /> Manufacturer: (11\ft R L Model: 2. 0 Year: 1 1 95 <br /> Manufacturer serial number HUD number <br /> a11419hb <br /> *Number of sections: a *Square footage:L'C\ *Number of bedrooms: ; *Number of bathrooms:ca <br /> *Type of roofing: rDty *Type of siding: ��.-C ` *Heating: IA f *Cooling: <br /> *Date of sale: *Sales price: *Includes land:❑Yes j31 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 /> • <br /> Transporter name: Transporter address and phone: <br /> ttge <br /> 440-2952(7/19/COM) Page 2 <br />