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• <br /> r` <br /> ' ' ' Assessor's Office <br /> DOUGLAS 1036 SE Douglas Ave. Rm 206 <br /> COUNTY <br /> • Roseburg,OR 97470 <br /> (541)440-4222 MH@co.douglas.or.us, <br /> • <br /> • <br /> COUNTY CERTIFICATE . <br /> Douglas County has received notice of Ownership Document Application for a manufactured home. <br /> NATURE OF FILING <br /> • <br /> fit Location Change ,fig Owner Change Tr i r\�-�- . . <br /> If moving,proposed location:55D.S', cu'��1' J ,L•� drl.S-J`k.• h'iark U'2 <br /> q-7 <br /> APPLICANT INFORMATION <br /> 0 .Dealer/Seller. D Lender � Escrow/Title Agent CI Owner/Buyer D Legal Representative , <br /> • <br /> ,NAME: ATY\.e.f C0. 1 i,t.-a_nc. Com-Pea-el <br /> ADDRESS: '7-I^1 CCnYIYY- •sr6,4� sE I c3!'� co Scdprm, Q2 ci 3 D <br /> PHONE:' •,-5 h41n5 D (3,m, Corti1 <br /> HOME INFORMATION <br /> HOME ID: 9 G D(p 3Z DMV X-PLATE NUMBER: <br /> D MOVING IN FROM ANOTHER STATE 0 OTHER <br /> COMING FROM ANOTHER COUNTY <br /> MAN UFACTURER:ra - - MODEL: L rvt..r\O YEAR: L9 7 <br /> NUMBER OF SECTIONS: eR DATE OF SALE: SALE PRICE: <br /> tfteir <br /> ()_..) Ate,,; €_. u i I <br /> Signature(Assessor or Representative) Printed Name <br /> P6SasSmPfa 1 k:t t (-(- ! ( o la 3 <br /> Title Date <br /> This certification is valid through: tS/ /D / oZ <br /> • <br /> Effective September 19,2017 <br />