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' 1V ,4\ q ] j�1411327 3AT 0 v A\i'c. Kt\ ` 6 3 lD v <br /> NATURE OF FILING (check all that applies) <br /> Eh.s - e ,r N 's -r: t r age s e o ' a em n: <br /> ego a e pr e in frre 1 p o rty_st `' ,'rip permit 'Z p to . .storage <br /> \�--y� <br /> APPLICANT INFORMAL ON <br /> 0 Dealer/seller i Q Lender 1 Q Escrow/title agent 1 — wner/buyer ID Legal representative <br /> Name:Jennie Neal <br /> Address (including city, state,and ZIP): 340 5TH AVE NE MILL CITY OR 97360 <br /> Phone: <br /> Email: <br /> HOME INFORMATION (*•required). <br /> Home ID number(if known): DMV X-plate number if known): <br /> M a3�,33 NEV <br /> fl Moving in from another state <br /> Has no home ID or X-plate because: Coming out of county deed records <br /> []Other: <br /> Manufacturer: CLAYTON Model: HOMES <br /> Year:2021 <br /> Manufacturer serial number HUD number <br /> ALB040284ORAB <br /> *Number of sections: a *Square footage:)` ao *Number of bedrooms: 4-1 *Number of bathrooms: c) <br /> *Type of roofing:At. *Type of siding: t- F'I *Heating:,1 e�f(�C r 4*Cooling: 0 f <br /> *Date of sale:g/ o2( *Sales price: rig, 1 G c *Includes land: 0 Yes No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> CLAYTON HOMES ALBANY, OR DLR #/MSD195 1437 CENTURY DRIVE NE <br /> CCB #166990 ALBANY OR 97322 <br /> (541)967-8555 <br /> 0 This manufactured structure is free and deaf 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 for perjury. <br /> De•ler name ,riot): Deale ,signature: <br /> I he(1. <br /> \tin _ t11c5 fl �?� IZfJZo <br /> TGR a(2 d — <br /> RTER INFORMATION f not moving, leave blank)nk) <br /> Transporter.name:.. .__-__ . Transporter address and phone:514(_30 7.--no S <br /> SUF)Grio( (kinin ��4Kpft- ILC 451 ( i of -fer,saa oa r <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TitleApp11211 Page 2 <br /> 004396455-00001 <br />