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• <br /> • <br /> NATURE`QF FILING (check all that applies)' <br /> ❑change security interest 0 Change ownership ❑Demolition Date of demolition: • <br /> • <br /> ❑Recording as real property ❑ Removing from real property status ❑Trip permit ❑Converted to storage • <br /> CI Other: • <br /> • <br /> } 1 APPLICANT INFORMATION <br /> • ❑Dealer/seller ❑Lender 111 Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name:Dalila Hernandez <br /> Address(including city,state,and ZIP):2401 E Katella Ave Ste 400,Anaheim, CA 92806 <br /> ;`Phone;(866)321-3153 - ` ` ' " <br /> • <br /> ,,Email:dhernandez@triadfs.com <br /> • <br /> HOME INFORMATION,(*required) <br /> Home ID number(if known): DMV X-plate number(if known): - <br /> NEW_HOME " <br /> C Moving in from another state <br /> Has no home ID or X-plate because: ❑ Corning out of county deed records <br /> U Other: <br /> Manufacturer: PALM HARBOR Model: 310HD28603C Year:2023 <br /> •Manufacturer serial number • • • '" • • HUD number • • • .. <br /> • PHH3100R22-15374A ORE 560726 <br /> • <br /> PHH3100R22-15374B ORE 560727 <br /> • <br /> • <br /> • <br /> .*Nuri ber...of sectiorisf 2 *Square footage: 1620 *Number of bedrooms: 3 *Number of bathir6oins:.2 <br /> *Type of-roofing:Arch *Type of siding:Fiber Cern *Heating:Electric *Cooling:None . <br /> *Date ofsale:02/06/2023 • *Sales price:$170,447.50 S *Includes land: ❑Yes i❑No <br /> DEALER INFORMATION (lf nd dealer,'leave blanks <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> • <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 />