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,--- _ , y .ey v-r.) ; *-- <br /> • <br /> DocuSign Envelope ID:BC82F0C2-F6EE-4Ec..,C38-F05F91E29D16 <br /> -3 D:a. co 1\) by-A-it-I ov1< cRJ, Lyo <br /> 1447112 ns cr7 3 5 e <br /> NATURE OF FILING (check all that applies) I <br /> \I 1!,,' 11 I' • g• oe,• h*, ie. , It ♦a- ',,'r'.•, i 'on' <br /> , o, 4 t e r v• <br /> ��� g <br /> ,. ,o -. . , .- • ::. Trip permit o rt storage- <br /> _VI <br /> aPt <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller 0 Lender I 0 Escrow/title agentOwner/bu Owner/buyer❑ Y 10 Legal representative <br /> Name:Robert Johnstone <br /> !Address(including city,state,and ZIP):32246 NORTH FORK RD LYONS OR 97358 <br /> flPhone: <br /> !Email: <br /> HOME INFORMATION (*required) _ <br /> Home ID number(if known): J DMV X- late number(f known):NEy�/ <br /> p &036, ` is, <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:SKYLINE MCMINNVILLE !Model:RAMADA VALUE `Year: 20 — <br /> �— <br /> Manufacturer serial number 20_Year: <br /> HUD number <br /> 245000HA100368AB <br /> *Number of sections: 2. *Square footagee: OO (*Number of bedrooms: <br /> a.—__ *Number of bathrooms: j <br /> *Type of roofing: et e/L s 1,ivyt. *Type of siding: * <br /> g L, ( Heating: 1 e c{-�; '*Cooling: <br /> *Date of sale: 1 0 I al 1,ca 1 *Sales price: 1 i 19 6 4 *Includes land: 0 Yes ®No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: <br /> Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR <br /> iiln S p ' 1437 CENTURY DRIVE NE <br /> / ALBANY OR 97322 <br /> _ (541)967-8555 <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 <br /> is made for use as evidence in court and is subject to-penalty '' perjury. <br /> Dealer name(print): Dealer signa I <br /> C Al 400 N o m VS Dealer <br /> Date: { <br /> "�?� I /0 121741 <br /> TRANSPORTER INFORMATION (i" not moving,Aeave blank) <br /> Transporter name: Transporter address and phone: r q j - 32-1_ <br /> SLe✓rio r No►riz, 'r,rAn,Jpt�Q —'�5 7 N 6+1,_.- eF�e,rson) oR <br /> 9 135 <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TitleApp 11211 Page 2 • <br /> 004489498-00002 <br />