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i-q C 0--c- Lounc., C-70.,k-e5 611-31 L <br /> NATURE OF FILING (check all that applies) <br /> ❑Change security interest 0 Change ownership ❑Demolition Date of demolition: <br /> ❑Recording as real property ❑Removing from real property status 0 Trip permit ❑Converted to storage <br /> ❑Other: <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 <br /> ID number(if known): DMV X-plate number(if known):Nll - °LA <br /> 9 CO <br /> ❑Moving in from another state Lc q` EI r 5) <br /> Has no home ID or X-plate because: ['Coming out of county deed records <br /> ❑Other: <br /> Manufacturer:PALM HARBOR Mode1:3105G42483A Year:2022 <br /> Manufacturer serial number HUD number <br /> • <br /> PHH3100R21-14775A ORE 556789 <br /> PHH3100R21-14775B ORE 556790 <br /> PHH3100R21-14775C ORE 556791 <br /> *Number of sections: 3 *Square footage:1863 *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: 12/15/2021 *Sales price: 176,599.20 *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 /> *This manufactured structure is free and clear of all mortgages,deeds of trust,security interests,and Iiens.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 /> ACag <br /> Dealer name(print): Dea er s'gna A Date:r' <br /> HOMES DIRECT OF OREGON LLC MILLERSBURG CD , �� !/�v/Wa' <br /> U441 <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/l9/COM) Page 2 <br />