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t35 �1 1k koYyl Dv-. E ons et X35 <br /> NATURE OF FILING (check all that applies) <br /> L n s 6 ■❑ Change ownership Me a,oNti•n o 8- . ' ion <br /> ece gin• •:re: , or- 1 : -m. fro. + : •.ert - .* s Trip permit o i t. s o ge <br /> L her: <br /> APPLICANT INFORMATION. <br /> 0 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): 1 3 4 DMV X-plate number(if known): rr11 VV <br /> NEW I l� aso, <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> ❑ Other: <br /> • <br /> Manufacturer:PALM HARBOR Model:310HD30633F Year:2022 <br /> Manufacturer serial number HUD number <br /> PHH3100R21-14779A ORE 556798 <br /> PHH3100R21-14779B ORE 556799 <br /> *Number of sections: 2 *Square footage:1180 *Number of bedrooms: 3 *Number of bathrooms:2 <br /> *Type of roofing:ARCH *Type of siding:FIBER CEM *Heating:NATURAL GAS *cooling:NONE <br /> *Date of sale: 12/29/2021 *Sales price:$168,688.50 *Includes land: ❑ Yes ■❑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 /> 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): Deal-r si,nat 11,4V sr-4.("/TA" ''' Date: <br /> HOMES DIRECT OF OREGON LLC MILLERSBURG Olt- / ' 4 P . g7 1/.- -- <br /> T-7/YrG , <br /> TRANSPORTER INFORMATION (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 />