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la5oOo Tai 1Pck Rol 6E, Lyons ci -235b <br /> NATURE.OF FILING (check all that applies) <br /> at r s •u ' n '.hange ownership ao .n ;. o' a•m ti - <br /> d co t:.: a' iii r..:r ' .io 'n '-.t t ❑� Trip pennitv r r b <br /> ae er: <br /> APPLICANT INFORMATION <br /> Q Dealer/seller ❑ Lender ❑ Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Namc:LEISURELAND HOMES INC <br /> Address(including city,state,and ZIP): 33964 OAKVILLE RD SW ALBANY OR 97321 • •• <br /> Phone:541-928-1555 <br /> • Email:mindy2lm@comcast. net • <br /> • HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): pp��,, A <br /> NEW (`:114488 • <br /> ❑ Moving in from another state <br /> Has no home ID or X-plate because: Coming out of county deed records <br /> • Other: NEW <br /> Manufacturer:FLEETWOOD WAVERLY CREST Model:28563W Year•:2022 <br /> Manufacturer serial number HUD number <br /> • FLE2100R21-22007 A&B ORE 557116 <br /> ORE-556117 <br /> • <br /> *Number of sections: 2 *Square footage:1492 *Number of bedrooms:3 *Number of bathrooms:2 <br /> • <br /> *Type ofrooting:ARCH . *Type oisiding:CEMENT *Heating:ELEC *Cooling:NONE <br /> *Date of sale:11/11/2021 *Sales price:118,545.00 *Includes land: ❑ Yes •No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: • Dealer address and phone: <br /> LEISURELAND HOMES INC MSD 119 33964 OAKVILLE RD SW ALBANY OR <br /> 97321 <br /> 541-928-1555 <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 kns''edge and belief, and that I understand it is <br /> made for use as evidence in court and is subject to penalty for per . <br /> - • Dealer name (print): Dealer Signa` e: Date: <br /> LEISURELAND HOMES INC • ' 6742- <br /> TRANSPORTER INFORMATIO (if not moving, leave blank) <br /> Transporter name: Trans orter address and phone: <br /> LEISURELAND HOMES INC 33964 OAKVILLE RD SW ALBANY OR 97321 <br /> 541-928-1555 • <br /> • <br /> • <br /> 440-2952(7/19/COM) Page 2 <br />