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. NATURE OF FILING (check all that applies) <br /> Change security interest 0 Change ownership ❑Demolition Date of demolition: <br /> ❑Recording as real property ❑ Removing from real property status IX Trip permit n Converted to storage <br /> ❑ Other: <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller ❑Lender ❑Escrow/title agent II Owner/buyer ❑ Legal representative <br /> Name:Crystal Jimenez • <br /> Address (including city, state, and ZIP): 1475 Carina Dr SE Salem 97302 <br /> Phone:503-851-9054 <br /> Email: <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): (o o4 0-7-3280511 X133 3 ®� <br /> ElMoving in from another state 3 a ail <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> n Other: <br /> Manufacturer:Golden West Model: Year:1998 <br /> Manufacturer serial number HUD number <br /> GW0R23N 19064 <br /> *Number of sections:2 *Square footage:13A3 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type ofroofing:Comp *Type of siding:T1-11 *Heating:Forced Air *Cooling:N/A <br /> ca= <br /> *Date of sale:Q • �i�� *Sales price: P/ 6),600 *Includes land: ❑Yes El No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <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 is <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print): Dealer signature: Date: <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> 440-2952(7/19/COM) Page 2 <br />