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3 NoyA-11, ,o ✓ V Ra. SE kydri <br /> NATURE OF FILING (check all that applies) / <br /> INZAr r st ■❑Change ownership ion a o m on: <br /> e nhs p t r e 1 a ❑■ Trip permito rt s <br /> er: <br /> APPLICANT INFORMATION <br /> O 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(f known): <br /> NEW ( D o 4-1 S <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:310H D28443A Year:2022 <br /> Manufacturer serial number HUD number <br /> PHH3100R21-14588A ORE 555672 <br /> PHH3100R21-14588B ORE 555673 <br /> *Number of sections:2 *Square footage: 1188 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:ARCH *Type of siding:FIBER CEM *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:7/27/2021 *Sales price:108,285.00 *Includes land: ❑ Yes O 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 /> OThis 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 /> hereby declare that the abovestatement istrue to the best of myknowledge and belief,and that I understand it is <br /> I e eby st e <br /> made for use as evidence in court and is subject to penalty for perju <br /> Atdet4 <br /> Dealer name(print): Dea er s'gna ••• '� / " Date: <br /> HOMES DIRECT OF OREGON LLC MILLERSBURG , " D Y 9 reGe_„ /e/oe/a/ <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 p <br /> 440-2952(7/19/COM) Page 2 <br />