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7 <br /> .1.a, q (1-'k CS etrY.ki Ctrn 17k0Li fq C <br /> NATURE OF FILING (check all that applies) <br /> ■❑Change security interest 0 Change ownership 1 I ':i'.1 '• Date : se Iti,• <br /> [ i co Nas'r ur6prty R: o ':•:ter. .o Is 0 Trip permit [ , onv raVollZage <br /> APPLICANT INFORMATION <br /> 0 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:TANYA.ABADILLA@HOMES,DIRECT <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> NEW CODC)41 <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:3105G42604A Year:2022 <br /> Manufacturer serial number HUD number <br /> PH H3100 R21-14455A 555446 <br /> PHH3100R21-14455B 555447 <br /> PHH3100R21-14455C 555448 <br /> *Number of sections:3 *Square footage:2436 *Number of bedrooms:4 *Number of bathrooms:3 <br /> *Type of roofing:ARCH *Type of siding:FIBER CEM *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:07/02/21 *Sales price:$180,018.50 *Includes land: ❑ Yes 0 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 NE <br /> 'MILLERSBURG MILLERSBURG OREGON 97321 <br /> 541-928-2083 <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 signatu � '' O —40.,(4.‘ <br /> Date:r / / <br /> HOMES DIRECT OF OREGON LLC MILLERSBURG 'ez-�©a GLS [!�i <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> BENNETT TRUCKING &TRANSPORT 409 BIGHAM BROWN RD <br /> JACKIE YOUNG EAGLE PT OREGON 97524 <br /> 541-879-3444 JACKIE YOUNG <br /> 440-2952(7/19/COM) Page 2 <br />