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.SECTION..1.. • NATURE OF FILING (check all that apply) ❑ New-borne-to-MHODS ❑' Adding or remo`vitig a co owner ❑ Demoliti n(Date: ) 1. Used home sale ❑ Recorduig as real property ❑''Converted to storage S--Security-interest_change_... ❑ RemovitigTraii`real properly status ( Trip Permit ❑ .Transfer by iiihcntance R. Other(please note): rem(h 4o di 4'-�4�w CGt I OTY1 SECTION•2 : .. APPLICANT INFORMATION (p ease :: • ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent 'Owner/Buyer ❑ Legal Representative N : (.�`e V �.t i'Q � I.� L� U�st, middle, last) l:.V o1 Phone: 3,2 7�y yJr—y� Address: '7 S .. t,j R er41 r e fr c1 /U City: S r- -W State: 0,2 ZIP: 973 e Email: \<1Q►'1� . CCA-Yl SECTION 3 OME•INFORMATiON (information:In bold`is required) Home ID#: eL f (/ 7 OR No Home ID: ❑New i-Iome ❑Out of state home/ ❑ Leaving County Deed Records Manufacturer: bbe `3 6)a t�v Model: Fervict Year: aD` Serial Number(s) HUD Label Number(s) *Required if new home #of Sections: Sq.footage: G q / Bedrooms: P2- Bathrooms: f Roofing type: Caryl Siding type: 1/1/) v / Heating type: E/e Cooling type: */e c f _ Date of sale: ;(//applicable) /�2-3�' Sale price: 37,Sas Includes land: ❑Yes [ 'No •SECTION 4 'DEALER INFORMATION,(leave blank If no:dealer) Name: (first,'middle, last) License it: Address: City: • State: ZIP: • Email: Phone: • I hereby declare this manufactured structure is free and clear of all mortgages, deeds of trust,security interests,and liens. I have the legal right to sell this manufactured structure or my interest in it. The information listed is true to the best of my knowledge and belief,and I understand it can be used as evidence in court and is subject to a penalty of perjury. Signature: Date: SECTION 5. +• ::HOME LOCATION .'. :` Current Address: '73.2s wtt 1 �.1 rl^�— 'ALL /V t= City: 5/ I u•-e County:ma r(0 en State: 6 e Zip:9 7 asp/ Park Name: (if applicable) El This is a dealer lot or storage facility YThls home is being moved to a new location Complete the section below New Address: 76 L/5"- City: `e,(U Q.(5. County:Mct r p State: 0e Zip: 9'7036, Park Name: (if applicable) ❑This is a dealer lot or storage facility Transporter Name: Phone: Address: City: State: Email: Page 2