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. 5\ <br /> A . <br /> I it' ne__A 1 Dr SE ,,, <br /> 1504858 f s q 7 VC <br /> ��' NATURE OF FILING(check ell thet.appliee)• <br /> Val 'ng c to s e 1• ' <br /> eThetitaiffkalificm(1/4-- <br /> Weetabl a r a e 1 re o g <br /> Trip permit a ed to storage <br /> e_r: <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller I Q Lender 1 Q Escrow/title agent J 'owner/buyer I Q Legal representative <br /> Name:Sylvia Machado <br /> Address(including city,state,and ZIP):4514 FIR DELL DRIVE SOUTHEAST SALEM OR 97302 <br /> Phone: R.71 ZO 10 I a 8' <br /> Email: 1Bt II J/ ' <br /> 1"`AGhOL®iQ �t 1A �. COS. <br /> HOME INFORMATION(*required) <br /> Home ID number(if known): DMV X-NE:wplate number(if known): <br /> 0 Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> 11 Other: <br /> Manufacturer:CLAYTON IModel:DRM 521M <br /> 1Year: 2023 <br /> Manufacturer serial number 1 <br /> HUD number <br /> ALB042155OR <br /> *Number of sections: 1 *Square footage: C O *Number of bedrooms: 2 *Number of bathrooms: <br /> *Type''ofroofmg: f1rct+' J � 1 <br /> St,;.5 *Type of siding: if r PRhG 1 *Heating: �fGG�'r�t- *Cooling: <br /> N�r4 <br /> *Date of sale: t%1/ 3 *Salesprice: * <br /> �'I,�3�', �O Includes land: ii Yes RNo <br /> DEALER INFORMATION(if no dealer,leave blank) <br /> Dealer name: Dealer lizeM r#ue b 195 Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR CCB fl166990 , 1437 CENTURY DRIVE NE <br /> ALBANY OR 97322 <br /> (541)967-8555 <br /> Q 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 <br /> is made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print): <br /> Vutl f Dealer signature: <br /> Date•C(e.y Fon Home-1017rCKA0016L'e-r— 1 I i ii'a <br /> TRANSPORTER INFORMAT (if not moving, leave blank) <br /> Transporter name: Transpor r address and phone: <br /> tennc 14. rhak;f <br /> 5 <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TitleApp11211 Page 2 <br /> 004663098-00003 <br />