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• <br /> :r • <br /> r NATURE OF FILING (check all that applies) . , _ .- <br /> a ecur' inte Change ownership *----Demo • ':_ : e i . . . • , _,_____ <br /> • rc n from reallropeu�t� tatyg ;.:i Trip permit - s a,` <br /> • APPLICANT INFORMATION <br /> • El Dealer/seller ❑Lender ❑Escrow/title agent • <br /> ❑ Owner/buyer 111 Legal representative <br /> Name:Kasandra Hills . <br /> • Address(including city,state,and ZIP):PO Box 11 Mill City, OR 97360 <br /> Phone:503-949-7943 <br /> . Email: sandy.pippin©yahoo.com <br /> HOME INFORMATION (*required). . <br /> _ Home ID number(if known): ! DMV X-plate number(if known): <br /> S(9C\0\S511067-8 _: <br /> 1-7 Moving in from another state <br /> • <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> • . . ❑ Other: <br /> • Manufacturer:Skyline Model: • Year: //.3,W <br /> Manufacturer serial number HUD number <br /> 0 f(. 15Gio9 . <br /> • <br /> bike- C 5.5i 1 <br /> -1•1.1-1 .4 3891 0 12) <br /> *Number of sections:2 *Square footage:1868 *Number of bedrooms:3 *Number of bathtooms:3 <br /> • *Type of roofnng:shingle • *Type of siding:vinyl *Heating:wood *Cooling:NA <br /> *Date of sale:11/01/2021 *Sales price:$0.00 (FIRE DONATION) *Includes land: ❑ Yes I• No <br /> '.DEALER INFORMATION (if no dealer,leave blank). • •• <br /> •Dealer name: Dealer license number: Dealer address and phone: - <br /> /V4 <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 U»znt): Dealer signature: Date: <br /> • • • TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> • <br /> 440-2952(7/19/C0M) Page 2 <br />