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kApact.. n SE � t�V ne <br /> 1434628 <br /> NATURE OF FILING (check all that applies) <br /> Change security interest Q Change ownership —Demolition Date of demolition: <br /> t — _ <br /> [Recording as real property 10 Removing from real property status IN Trip permit Q Converted to storage <br /> []Other: <br /> APPLICANT INFORMATION <br /> Dealer/seller (Q Lender IL Escrow/title agent [Owner/buyer [Legal representative <br /> Name: Jacob Daniel Cantrell <br /> Address(including city,state,and ZIP): —Sri yR1DGEWAY DRIVE SE TURNER OR 97392 <br /> Phone: <br /> Email: <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 0 X48 <br /> I[Moving in from another state <br /> ri Coming of deed records <br /> Has no home ID or X-plate because: ng outcounty <br /> Other: <br /> Manufacturer: CMH Model: 72SSR2872AH21 IYear: 2021 <br /> Manufacturer serial number HUD number <br /> ALB040858ORAB -- <br /> *Number of sections: �_ *Square footage/5 4/7 *Number of bedrooms: *Number of bathrooms: , <br /> *Type of roofing: *Type of siding: *Heating: Coolin : <br /> ��f� I f/L <br /> *Date of sale: ., 7No <br /> 1* g*Sales price: 4j. 9 *Includes land: Yes:0 <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealerliceo r1)t :i 95 Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR CCB #166990 1437 CENTURY DRIVE NE <br /> ALBANY OR 97322 <br /> (541)967-8555 <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 <br /> is made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print): Dealer signature: Date: <br /> •t to il.' ' _IL;LA _ k it <br /> TRANSPOR'ER INFORMATIe (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: —) <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TitleApp11211 Page 2 004450127-00002 <br />