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• <br /> - I ()I 5 \Thr> kte , , <br /> Li -7 3 <br /> DocuSign Envelope ID:DF1E0505-18B3-4075-9EOF-DBFB C9AFC <br /> - Lyons <br /> NATURE OF FILING (check all that applies) <br /> a ct • st 0 Change ownership eAi a of o ' on <br /> e o in s pe m 0 Trip permit e ec dgrage <br /> er: <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 ID number(if known): DMV X-plate number(if known): <br /> NEW CD 040(01 <br /> 7 Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records. <br /> ❑Other: <br /> Manufacturer: PALM HARBOR Model:310HD30643B Year: 2023 <br /> Manufacturer serial number HUD number <br /> • PHH3100R22-15351A ORE 560681 <br /> PHH3100R22-15351 B ORE 560682 <br /> *Number of sections: 2 *Square footage:1857 *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: 1/26/2023 *Sales price: $202,421.00 *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 /> 0This 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): De er signature: Date: <br /> DIRECT OF OREGON LLC MILLERSBURG 3/�AkJ <br /> • TRANSPORTER INFORMATIO (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(7/19/COM) Page 2 <br />