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eo <br /> \! II Y qt \l S . WI�3 O Ll -7 3 4 L <br /> a <br /> NATURE OF FILING(check all that applies) <br /> a age se ur i est ❑ Change ownership Ilk 1- on D. - of I- .olit on: <br /> or.:..g :: r ro.: __ • -:10 g . •!• ..a .•.p- .tus •Trip permit lci..0 ve st age <br /> IIII •ther: <br /> APPLICANT INFORMATION <br /> ❑■ Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name:HOMES DIRECT OF OREGON LLC MILLERSBURG <br /> Address (including city,state,and ZIP):3838 PALM HARBOR DR MILLERSBURG OR 97321 <br /> Phone:541-928-2083 <br /> Email:MARK.GORMAN@HOM ES.DI RECT <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): �/ DMV X-plate number(if known): <br /> 0 64 )5) <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:PALM HARBOR Model: ?to U4 �i Year:2021 <br /> Manufacturer serial number HUD number /� <br /> PHH 31b DR„ZI —1%-1 (01 ORE j S �I 1 I <br /> PHH 310 0Ll( - I 49(P3B ORE 5 5 <br /> *Number of sections: Z- *Square footage:) ,lam *Number of bedrooms: *Number of bathrooms: Z <br /> *Type ofroofmg: Av-1.4 *Type of siding: 1c *Heating: E(G *Cooling:NONE <br /> *Date of sale: �}l'� '2(jZ I *Sales price: l 5k-A L? s, *Includes land: ❑Yes Ei No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> HOMES DIRECT OF OREGON LLC MSD-523 3838 PALM HARBOR DRIVE <br /> MILLERSBURG MILLERSBURG OREGON 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. �4 <br /> Dealer name(print): Dealer signature: (2Y1 &`JCC/k Date: 4—I 2 r <br /> 6O?i6y'\ LLC W % bli `i <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> BENNETT TRUCKING 409 BIGHAM BROWN ROAD <br /> EAGLE POINT OREGON 97524 <br /> 541-879-3444 JACKIE YOUNG <br /> 440-2952(7/19/COM Page 2 <br />