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al C\oerwL S , rnv <br /> NATURE OF FILING (check all that applies) = " <br /> aglilogiatetitily-fiiterest ErChange ownership Ekenfaitia-lhatert5N16-n1)00 <br /> ro m 'Trip permit ' oer ed tb-sto e <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller 0 Lender 0 Escrow/title agent Ea-Owner/ism. ❑Legal representative <br /> Name: Th'NN TS, 1.1,C, ( C oq-a9i J i) <br /> Address(including city, 40 . <br /> state,and ZIP): tS )t,ti 'r 4k'L� ?9. 5 SA-tiot.;ft� co 3� li.:.:'' <br /> ti <br /> Phone:. _ U3-- - - . ... .._. <br /> Email: 4v ii 5 51 ( /RA..(-,-m <br /> HOME INFORMATION (*required) <br /> Home ID number(f known): DMV X-plate number(if known): <br /> 401.1 • <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> ❑Other: T (S ecr CDve) <br /> Manufacturer: Model: 3 ipi.1'i).20uo 3C Year: 2016, <br /> Manufacturer serial.number HUD number <br /> PN/43)0kI(o )I ci4q A <br /> *Number of sections: .2 *Square footage:hi,26 *Number of bedrooms: *Number of bathrooms: 2. <br /> *Type of roofing: 5hi, l t *Type of siding:1-- ( I *Heating: F1X.6 c d A'r *Cooling:It ex-rr-f <br /> �. .. <br /> *Date of sale: Z -1 S-20"L L *Sales price: 75)OCO � *Includes land:❑Yes (a-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 /> T 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 /> '-'RAcKAN(. Z 4 �to Jk rri P-0 <br /> J\-uJ c1a c) "1 IS <br /> X <br /> 440-2952(71171C0M) , Page 2 <br />