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C\oerak \ S ILtrnv <br /> NATURE OF F1UNG (check all that applies) <br /> g s n ["Change ownership o ' 'o m i • <br /> S ro m RfTrip permit i e . <br /> aCelar. <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller ,❑Lender ❑Escrow/title agent 531)wner/b 0 Legal representative <br /> Name. - U`v5 vriAl S I.LG (co.ni0E, C_fi-a.eiN ii,4k) <br /> Address(including'city,state,and ZIP): 11045 it.A VLAr �L� P,9 S Sittgatiti ot. .7.3_ <br /> Phone: :cti .-2)% Tc, <br /> Email: jZNI€S s7 L A�U+-•C.�`m <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 401.15-r <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> ❑Other: _77 (S ecr Cove) <br /> Manufacturer. -pC1d M �Y C l�f Model: 3 i014 1,206,03G Year. 2016, <br /> Manufacturer serial number HUD number <br /> VNN31OfI(p ,:cl4g <br /> *Number of sections: .2 *Square footage:/to J *Number of bedrooms: - *Number of bathrooms: Z <br /> *Type of roofing: Shirvl t. *Type of siding: — ( l *Heating: 1.1 u �e et.L'( *Cooling: --- <br /> *Date of sale: i 2 -(S-20'LL_ *Sales price: lit 61 CW ice/ *Includes land:❑Yes W Io <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 /> Y,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 /> Lid i(W c g i'y 1, Z't H`)l0 11AV k* P-4 <br /> iLr \00, 611 1 0 1 <br /> 440-2952(7n7/COM) Page 2 <br />