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r <br /> r <br /> • <br /> NATURE OF FILING (check all that applies) . • <br /> �ecur�tymtert [I] Change ownershipemo ' ' $ P , <br /> .. . . .'.a c • i ! s� 'rte from real lroperi Trip peimit 'E— a*„ <br /> APPLICANT INFORMATION <br /> EJ Dealer/seller ❑Lender ❑Escrow/title agent <br /> ❑ Owner/buyer El Legal representative <br /> Name:Kasandra Hills <br /> Address(including city,state,and Z1P):PO Box 11 Mill City, OR 97360 <br /> Phone:503-949-7943 <br /> Email: sandy.pippin@yahoo.com <br /> • HOME.INFORMATION (*required), <br /> • <br /> Home ID number(if known): ') J DMV X-plate number(if known): <br /> cp�,�� 51-1c67-3 <br /> (1 Moving in from another state <br /> Has no home ID or X-plate because: [ Coming out of county deed records <br /> • n Other: <br /> Manufacturer:Skyline Model: Year: / ' 0 <br /> Manufacturer serial number HUD number <br /> off.. 5G b9 <br /> Dike- 5 Si <br /> -14ie 3g9 <br /> *Number of sections:2 *Square footage:1868 *Number of bedrooms:3 *Number of bathrooms:3 <br /> *Type of roofing:shingle *Type of siding:vinyl *Heating:wood =Cooling:NA <br /> *Date of sale:11/01/2021 *Sales price:$0.00 (FIRE DONATION) *Includes land: ❑ Yes El No <br /> DEALER INFORMATION (if no dealer, leave blank). <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> • <br /> 114 <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(pint): Dealer signature: Date: <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> 440-2952(7/19/COM) Page 2 <br />