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• <br /> 100 . _ "Cl 8 A-• jr /+- <br /> NATURE OF FILING (check all that applies) <br /> KKALn.gteNs.eied-nNAQrest 0 Change ownership MI mo ' o ►, e . de-.lit'. <br /> "CO •' ga -a . •,e 1 ' -m. is: .• . ,r' • _ . . El Trip permit [19 ( n - -d .• - o •- <br /> .Other: <br /> APPLICANT INFORMATION <br /> 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(if known): <br /> NEW (0OO4 1B <br /> ❑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:PALM HARBOR Model:310HD30763H Year:2022 <br /> Manufacturer serial number HUD number <br /> PHH3100R21-14623A ORE 555747 <br /> PHH3100R21-14623B ORE 555748 <br /> *Number of sections:2 *Square footage:2213 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:ARCH *Type of siding:FIBER CEM *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:9/3/21 *Sales price:$177,455.00 *Includes land: ❑ Yes 0 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 /> 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 / ,/;�/1 <br /> Dealer name (print): Dealer s'gnatu ;. i , 'bG���`'or�, Date: <br /> HOMES DIRECT OF OREGON LLC MILLERSBURG % ' " ��r�p�l� G� /d7/g"/ <br /> / K lJ " ` <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 <br /> 440-2952(7/19/COM) Page 2 <br />