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Oct, 1. 2021 10:45AM Marion County No. 1195 P. 3/6 <br /> NATURE.OF:FILING (check applies) <br /> ❑Change security interest 0 Change ownership • 0 Demolition Date of demolition: <br /> ❑Recording as real property ❑Removing from real property status []Trip permit ❑ Converted to storage <br /> ❑ Other: <br /> ,APPLICANT INFORMATION. <br /> •Dealer/seller []Lender r❑Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> _Name: <br /> Address(including city,state, and ZIP):. <br /> Phone: <br /> Email: • <br /> HOMEINFORMATION'(*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coiningcounty out of deed records <br /> ❑ Other; <br /> - Manufacturer; .L3 1' Model: Year: f,Cye( <br /> MAnufacturerIerial number HUD number <br /> 3,-J-3-)-- OR.E 3 4, 2 ECC . <br /> 3'a-3 •-- PS E 3 G a. 5%57 <br /> - _ r <br /> *Number of sections: *Square footage: I 9, *Number of bedrooms: off-- *Number of bathrooms: 'a„ <br /> 'Type of roofing; *Type of siding: �'1 b� "Heating: 'Cooling; r�} <br /> 'Date of sale; q— *Sales price: �"p ; 'Includes land; ❑Yea IMNo <br /> DEALER INFORMATION (If no.deale'r, 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 /> ®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 si Date: <br /> Doug Walton' d <br /> TRANSPORTER INFORMATION (If nomoving, leave blank) <br /> Transporter name: Transporter address and phone: • <br /> Dougs mobile home service Inc 12692 Fry rd no Aurora <br /> 440-2952(7/19/COM) Page 2 <br />