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I <br /> 155 tAir>ca&. r De_ �� , 11 , See -ems ---/ 65 <br /> • <br /> NATURE OF FILING (check all that applies) <br /> II ge uri '. Chaage ownership -- <br /> /3 Re .':ti,Q a .r. p.,,$ire `p t2' � , {, '-N <br /> [�Ot�er: `�" i`�[�TdP Permit n e <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller 1 ❑Lender —❑Escrow/title agent _MOw/ler/buyer ❑Legal representative <br /> Name: Juan Toriz <br /> Address(including city,state, and ZIP): 4155 Lancaster Dr NE Salem, OR 97305 <br /> Phone: 503.954.7705 <br /> Email: Jtforwardin@gmail.com <br /> HOME INFORMATION (*required) <br /> Home.ID number(tflo:own): DMV X-plate nnrnber(f ltnown): <br /> aa336� x I 5131 8,4 ( (6.0 81 <br /> ❑Moving in from another state <br /> Ras no home ID or X-plate because: [] Corning out of county deed records <br /> El Other: <br /> Manufacturer. Model:UNKNOWN J Year. /9 7 7 <br /> Manufacturer serial number HUD number <br /> 37/n4rs 7 ✓n <br /> "Number of sections: *Square footage: ,f 52 *Number of bedrooms: 2 'Number of bathrooms: 2 <br /> 'Type of roofing:W�`ti s 1*Type of siding: � ,� ( "Hearing: el�.G},r;c <br /> *Cooling: cu ef- <br /> *Date of sale: r I/2 2^ Sales price: II COO "Includes land:El Yes g No <br /> } DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number Dealer address and phone: <br /> Vtll¢�e,\-1‘-ow%e.s 1tW LLc tYl5 © 4.64 k55 fvE T7nree.07,(e ►-+A• <br /> J QYI�t'tt:crvursa, C 'rya.? <br /> r»3� <br /> tr/Z-13t5 <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 /> r hereby declare that theabove statement is true to the b of my kno dge and belief,and that I understand it is <br /> made for use as evidence in court and is subject to penal for perjury. <br /> Date: <br /> Dealer name(print): D s��namre: <br /> V,c4e-limas Au�l_� 1 _.. I/ i/2 <br /> 1 <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> 'Transporter name: Transporter address and phone: <br /> 2390 Alameda st. NE <br /> Site Inspection Services Salem,Or 97301 <br /> 503.375.9440 <br /> 440-29S1(7/19/COM) Page 2 <br />