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• <br /> 4 v7 ne__,‘ <br /> 1504858 S /1`el /�� 3C) <br /> 1 J <br /> NATURE OF FILING(check all that applies) <br /> �� dg\s c tos e o aVle . <br /> ¢or a r a a it re o stows [ Trip permit <br /> ed tutorage <br /> er: <br /> APPLICANT.INFORMATION <br /> [�Dealer/seller I Q Lender I Q Escrow/title agent 10 Owner/buyer I Q Legal representative <br /> Name:Sylvia Machado <br /> Address(including city, - .(• g ty,state,and ZIP):4514 FIR DELL DRIVE SOUTHEAST SALEM OR 97302 <br /> Phone: q 71 X01 01 e <br /> Email: Joa(y p'i o►64 A,4;r 4C o r"-t, <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> []Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> [�Other: <br /> Manufacturer:CLAYTON 'Model:DRM 521M <br /> �Mdl iYear: 2023 <br /> Manufacturer.serial number I HUD number <br /> ALB042155OR <br /> *Number of sections: 1 l*Square footage: 46,9 ,*Number of bedrooms: 2 !*Number of bathrooms: <br /> *Type of roofmg:• ` ��t'. <br /> Si,: 1 *Type of siding: Ld� �ayc! *Heating: IGG{^r-;e, *Cooling:. /(/l <br /> 4 <br /> *Date of sale: i/1/2 3 *Sales price:itel,.a ts":SO *Includes land: Yes gNo <br /> DEALER INFORMATION(if no dealer, leave blank) <br /> Dealer name: Dealer l' IFl_ ' .03b 195 ' Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR CCB #166990 1437 CENTURY DRIVE NE <br /> ALBANY OR 97322 • <br /> (541)967-8555 <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 <br /> is made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print): � c) e,y Dealer signature: <br /> C(tAy fun H JCS o a� Date <br /> TRANSPORTER INFORMAT (if not moving, leave blank) <br /> Transporter name: Transpor r address and phone: <br /> t$ned1'' t rhaIt; ^5 <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TitleApp11211 Page 2 <br /> 004663098-00003 <br /> A <br />