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M oat, 9 -1340 6 <br /> NATURE OF FILING (check all that applies) <br /> g- _- n es El Change ownership i -6 m iiti. •to o .-mo ...on. <br /> Lec di as p ert'}r ■ mo ro.• 31 traikestyllats 0 Trip permit n r o a <br /> ki .they:• <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): /f � <br /> NEW (F! O cam' 35 9 <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:3105G42744A Year:2016 <br /> Manufacturer serial number HUD number <br /> PHH3100R15-11579A-AC ORE 529050 <br /> PHH3100R15-11579B-AC ORE 529051 <br /> PHH3100R15-11579C-AC ORE 529052 <br /> *Number of sections: 3 *Square footage:2810 *Number of bedrooms:4 *Number of bathrooms: 3 <br /> *Type of roofing:ARCH *Type of siding:FIBER CEM *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale: 11/24/2015 *Sales price: 198,055.00 *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 /> jI 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 signatu : t i/ ' �y'�'/ Date: <br /> � //� <br /> HOMES DIRECT OF OREGON LLC MILLERSBUR , /� / // c 1/4'0- <br /> ak <br /> TRANSPORTER INFORMATI•N (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 />