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� � C <br /> 5 Scur-41�-;a rn Ae \v1d Orô <br /> I 7` 9. -7 4 - <br /> DocuSIgn Envelope ID:8B3B090D-DAE9-4ACB-A452-59AA00150A2E <br /> 1448441 <br /> _ NATURE OF FILING(check What applies _ <br /> c r 'aksat- ertyem . p pe'tf Matas j rip permitC to toragtr . <br /> a> en <br /> APPLICANT INFORMATION <br /> El Dealer/seller [j Lender Q.Escrow/title agent Q Owner/buyer El Legal representative <br /> Name:Susan Crowder <br /> Address(including city,state,and ZIP):275 SANTIAM AVE DETROIT OR 97342 <br /> F <br /> Phone: <br /> Email: <br /> HOME INFORMATION(*required) <br /> Home ID number(if known): �,-.\N/ DMV X plate number(ifknown) <br /> --- t0 O 3CP D-'-) <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: CMH . <br /> - _, <br /> (Model:DRM483F Year:2022 <br /> Manufacturer serial number IIUD number " <br /> ALB041168ORAB + — _ __ ___._--...__. <br /> • <br /> *Number of sections Z j*Square footage:/,fig Z�*Number of bedrooms: 7, J*Number of bathrooms: L <br /> *Type of roofing: * *Heating: f Coolin : <br /> YP g �' ,, Type of siding: �, Heat' <br /> *Date of sale:/)14-- z *Sales price:2,3'c- e 1*Includes land: 0 Yes J No <br /> DEALER INFORMATION (if no dealer,leave blank) —�_—` <br /> _..— _.__._._, <br /> Dealer name: <br /> Deal . :--_. ► - Dealer address and phone; <br /> CLAYTON HOMES ALBANY,OR DLR M{' '95 <br /> 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 <br /> Iegal right to sell this manufactured structure,• interests,and liens.I have the <br /> I hereby declare that the above statement is true to the bestf my knowledge and belief,and that I understand it <br /> is made for use as evidence in court and is subject to .etilty t 1 i erjury. <br /> Dealer name(print): -aler Si .1.re: 1Date:— �� <br /> /...4.t7,....4,....,.. A.6.,....., <br /> 7„,_(.3.4 <br /> o. <br /> TRANSPORTER INFORMATION(if not mning,leave blank) ( I <br /> 1_5, <br /> Transporter name: (Transporter address and phone: <br /> __ <br /> 440-2952(7/19/COM) <br /> ' OR Title Application-10/2019-TitleApp 1127 l Page 2 004499938.00002 <br />