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<br /> ❑Change security interest Change ownership ❑Demolition Date of demolition:
<br /> ❑Recording as real property ❑Removing from real property status •Trip permit ❑Converted to storage
<br /> ❑Other:
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<br /> ❑■ Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑ Legal representative
<br /> Name:Factory Expo Homes
<br /> Address(including city,state,and ZIP):2555 Progress Way,Woodburn, OR. 97071
<br /> Phone:503-981-0770
<br /> Email:moconnell@factoryexpohomes.com
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<br /> Home ID number(if known): DMV X-plate number(if known):
<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:Fleetwood Model: Macksburg 24342V Year: 2022
<br /> Manufacturer serial number. HUD•number
<br /> FLE2100R21-21894A ORE 556701
<br /> FLE2100R21-18948 ORE 556702
<br /> *Number of sections: 2 *Square footage: 793 *Number of bedrooms: 2 *Number of bathrooms:
<br /> *Type of roofing: Arch. Comp. *Type of siding: Vert. Cement *Heating: Electric *Cooling: None
<br /> *Date of sale:
<br /> . t'1:7..i...*+:..•t,./x iFr'+.,�.Y>at1N` tiY+h 01/05/2022
<br /> 1/05/2022 *Sa
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<br /> r£4,h,145.0..6,i. i.....l.. r.. : .r.*Includes
<br /> Includes land:❑ Yes NENo
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<br /> Dealer name: Dealer license number: Dealer address and phone:
<br /> Alta Cima Corp. MSD D 448 2555 Progress Way
<br /> Dba: Factory Expo Homes Woodburn, OR. 97071
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<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 /> 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 signature: Date:
<br /> Alta Cima Corp. 707.0'/eeh rr.Q./ 01/25/2022
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<br /> Transporter name: Transporter address and phone:
<br /> Superior Home Transport, LLC PO Box 1067
<br /> Jefferson, OR. 97352
<br /> 440-2952(7/19/COM) Page 2
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