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\ a Ga-L, i R <br /> r C , G CVes q `73� � <br /> NATURE OF FILING (check all that applies) <br /> ❑ 1'aage eeg _' te�cest ❑ Change ownership mo ' lon •to • de :lits: : <br /> or ng s r al p .s- \ `e 'o 1_ • -.tpiert i s atQs\ ❑® Trip permit MoifietatKaragey <br /> ,2ther: <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name: CASCADE FACTORY HOMES INC <br /> Address(including city,state,and ZIP): 590 N PACIFIC HWY,WOODBURN OR 97071 <br /> Phone: 503-981-5314 <br /> Email: CASCADE FACTORY HOMES <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-platc number(if known): <br /> (.0013oci <br /> ❑Moving in from another state (S 9 B$0 ) <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ❑Other: <br /> Manufacturer:Palm Harbor Homes Model:3104G28603D Year:2022 <br /> Manufacturer serial number HUD number <br /> PHH3100R21-14828A ORE 557636 <br /> PHH3100R21-148288 ORE 557637 <br /> *Number of sections:2 *Square footage:1,620 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing: ARCH SHING *Type of siding: CEMENT *Heating:ELECT *Cooling:N/A <br /> *Date of sale:3/18/2022 *Sales price:$135,244 *Includes land: ❑Yes j No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> CASCADE FACTORY HOMES INC MSD-41 590 N PACIFIC HWY <br /> WOODBURN OR 97071 <br /> 503-981-5314 <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 1 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 /> CASCADE FACTORY HOMES INC 1 ? 3/18/2022 <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> SUPERIOR HOME TRANSPORT LLC PO BOX 1067 JEFFERSON, OR 97352 <br /> 503-551-3454 <br /> 440-2952(7/19/C OM) Page 2 <br />