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\ 50 <br /> NATURE OF FILING (check all that applies) <br /> • <br /> a s u e s 0 Change ownership e i ' e ► : <br /> igt,ntain re o y e o ro e o y s Trip permit torage <br /> le ' _ <br /> • <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): 2// ��yy <br /> NEW f!CJ03(0 —1 <br /> Moving in from another state (5 M3`5) <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> ❑ Other: <br /> Manufacturer: PALM HARBOR Model: 3104G28483D Year: 2023 <br /> Manufacturer serial number HUD number <br /> PHH3100R22-15317A ORE 560427 <br /> PHH3100R22-15317E ORE 560428 <br /> *Number of sections: 2. *Square footage:1368 *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: 12/28/2022 *Sales price: $155,802.00 *Includes land: ❑Yes 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 /> OThis 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): D 1 r signature: �.��G< / Date: <br /> HOMES DIRECT OF OREGON LLC MILLERSBUR �,�( ,W/4Q/dV <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 />