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a 3 4 39 i v v kiE 64- P cuk <br /> NATURE OF FILING (check all that applies) <br /> N-OungAsktlity-givzst Q Change ownership a :,• .0 o 9 elcae' <br /> C,Inv in re p .•. I/ 'e .• • = c i st Ul Trip permit terN d s age - <br /> Other: <br /> APPLICANT INFORMATION <br /> 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): DMV X-plate number(if known): �q w <br /> NEW b3(0cikid\AAY: n�f' <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:PALM HARBOR Model:31 OHD30763A Year:2022 <br /> Manufacturer serial number HUD number <br /> PHH3100R21-14820A ORE 557178 <br /> PHH3100R21-14820B ORE 557179 <br /> *Number of sections: 2 *Square footage:2280 *Number of bedrooms: 3 *Number of bathrooms:2 <br /> *Type of roofing:ARCH *Type of siding:FIBER CEM *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale: 1/26/2022 *Sales price:$138,550.00 *Includes land: ❑Yes 0 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 /> El 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): De/a er s'gnatu -. i Date: <br /> HOMES DIRECT OF OREGON LLC MILLERSBURG D,1V� UL� 4-1/4 <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 />