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a55 V3 , U� <br /> • NATURE OFFLING:(check all that applies), <br /> ruisk4i Arest 0 Change ownership ► • o :.n r.. - -+ I;' o •n: <br /> aRe t r l a ty r_ . r ,e s 0 Trip permit VapAsslAcrworalie <br /> EVAer: <br /> APPLICANT INFORMATION <br /> El Dealer/seller 0 Lender 0 Escrow/title agent 0 Owner/buyer 0 Legal representative <br /> Name: <br /> Address(inclu g city,state,and ZIP): / J 7g_ F / liF Ou.)/`c`c ®,e?7� -� <br /> Phone: ____4-6)3 —797. efAsf <br /> Email: � � <br /> C�CJL � <br /> HOME INFORMATION-(*re <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 37 861 03ce D-1 <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: 0 Coming out of county deed records <br /> 0 Other: <br /> Manufacturer: pa i Model: Year:36i <br /> Manufacturer serial number HUD number <br /> PWW3 !oOv-1II, , 3A <br /> fi413I.04 von 8-3 1 <br /> *Number of sections: a *Square footage: /1 *Number of bedrooms: ! *Number of bathrooms: 1 <br /> *Type of roofing: C_ " !+ *Type of siding: arcly *Heating: / *Cooling: <br /> *Date of sale: *Sales price: *Includes land: Yes 53 No <br /> DEALER INFORMATION Of no dealer, 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 /> I 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 e: Date: <br /> Doug Walton <br /> TRANSPORTER P,.COOVIATIOW0f OtnitiVing, leave blank): <br /> Transporter name: Transporter address and phone: <br /> Dougs mobile home service inc 12692 Fry rd ne Aurora <br /> 440-2952(7/19/COM) Page 2 <br />