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. ' . . bb --1 1-1-rji Loci q9b-A,,,,cOr-, <br /> NATURE OF FIb1 check all that applies) <br /> an gArels*iAest 0 Change ownership loo ► ; <br /> o'se, o '-'o <br /> or ' g a pl em ' 12 Trip permiter to r ge <br /> ❑1Q.ther: <br /> APPLICANT INFORMATION . <br /> 0 Dealer/seller - ❑Lender ❑Escrow/title agent D Owner/buyer ` <br /> y ❑Legal representative <br /> Name: m rni ,b1.``e Rme_ .pi- \C <br /> Address(includinty,state,and ZIP <br /> Phone: (SD --- •t°t 1)S&9 <br /> I <br /> Email: .)(SL) --�t'1 ae)\ . 03 (\i\ <br /> HOME INFORMATION e:regeflred) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> NE-_-W N E v/ <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:_.5.Xy, `�► Model: Z ear: <br /> Manufacturer serial number I HUD number <br /> • <br /> f 20l'/o38'o7-aA i R 4 M7.3-.--Li <br /> *Number of sections: q footage: � <br /> *Square fry`�y f *Number of bedrooms:3 � Number of bathrooms: a <br /> 'Type of roofing: avyi *Type of siding: `Heating: C- e_c_r- 'Cooling: // c <br /> /(j� dr <br /> �' <br /> 'Date of sale: �v <br /> 3-7— �l I ,'Sales price: D ! eD I 'includes land: ❑Yes tglNo <br /> DEALER INFORMATII*N,(if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> Dougs mobile home service inc 652 12692 Fry rd ne Aurora OR 97002 <br /> 0 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): . Deal- sign re: Date: <br /> Doug Walton cc-7/(.1---• <br /> d'-07--?--L-2 <br /> s ?--2I <br /> TRANSPORTER INFORMATION TIO (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> Dougs mobile home service inc 12692 Fry rd ne Aurora <br /> . <br /> 440-2952(7/(9/COM) Page 2 <br />