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<br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent `X,OwnerBuyer ❑Legal Representative
<br /> Name: ` t
<br /> (first,middle,last) $--)-+ p� Phone: t7 i �j j
<br /> Address: .I f�j I W -1 6 ii'"`---"'�-�a
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<br /> City: ` Oacern State:Q� ZIPA I 1
<br /> Email: (J��y
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<br /> Home ID#: - 4rl •a-' . OR No Home ID: ❑New Home '2 Out of state home ❑Leaving County Deed Records
<br /> Manufacturer: COO(, qR 5
<br /> Model: • Year: 1 01(1.7
<br /> Serial Number(s) HUD Label Number(s)*Required if new home
<br /> •
<br /> #of Sections: I Sq.footage: .,.1• 1 ; Bedrooms:_ A e Bathrooms: 2.
<br /> Roofing type: p Siding type: —�'1 i`J Heating type: (y +J cooling type: Q
<br /> Date of sale: Salef
<br /> (Ijoppticah[e) OrZ� price:- Vs,000Includes land: ❑Yes o
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<br /> Name:
<br /> License#:
<br /> Urst,middle,last)
<br /> Address:
<br /> •
<br /> City: State: ZIP:
<br /> Email: _ Phone:
<br /> I hereby declare this manufactured structure is free and clear of all mortgages,deeds o.f trust,security interests,and liens.I have the
<br /> legal right to sell this manufactured structure or my interest in it. The information listed is•true to the best of my knowledge and
<br /> belief,and I understand it can be used as evidence in court and is subject to a penalty of perjury.
<br /> Signature: Date:
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<br /> Current Address: _ '
<br /> City: ioiinty: Mate J - Zi}
<br /> Park Name: (if applicable) • i I "l: pert storage facility •. ••
<br /> This home is being moved to a w location Complete the section below
<br /> New Address: 490 a 1 0.A , , ,
<br /> .
<br /> City: 8,i 6-11' County tm State:lJ�42 , Zir41 `1 I
<br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility
<br /> Transporter Name: i,M Ke_r__.y e_fi,.., / e._e_v'e_,s �omi.;i►-s Phone:&sd-9 7 ,-...z''p
<br /> Address: is R /h t:pi 6P,a Y'}' City: 4 j V i e..r) State: lcS,►9- G151,,s•3 •
<br /> Email:
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