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A . 16 C\overa,L R ,21 S UYnev <br /> NATURE OF FILING (check all that applies) <br /> acange—Atetifity-aerest IZChange ownership o o m r <br /> g ro WfTrip permit I iglafi3ertecrilmtalitge <br /> [fir. <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller Lender ❑Escrow/title agent (a'Owner/b_-fig;_ 0 Legal representative <br /> Mune:__.E,C,gL jN d$Th'1vNTS LLC, Cct,(LN bchee N <br /> Address(including city,state,and ZIP): 1-1t KS l t,t-klAcf'L kkkL-• 24. S Swot; <br /> `.:Phone: ;:.SU:3 >LZ).r c, � . .. ... . .... .... ... <br /> Email: frj2N l€S 5 i L MA..C,c'rn <br /> HOME INFORMATION (*required) <br /> Home ID number(f known): DMV X-plate number(ifknown): <br /> 401.7 <br /> 0 Moving in from another state <br /> Has no home II)or X-plate because: ❑Coming out of county deed records <br /> ❑Other: S ecr -Cove <br /> Manufacturer. 1y C[ Et r Model: 3 l 0 il>26 6,0 36 Year: 2O I(D <br /> Manufacturer serial number HUD number <br /> PO 3 R j`(p 1 I g 44q A <br /> *Number of sections: .2 *Square footage: � J *Number of bedrooms: -j *Number of bathrooms: 2. <br /> *Type of roofing: Shim't. *Type of siding: -- ( I *Heating Cooling: �- <br /> *Date of sale: 12 -(S-2.0'L L_ *Sales price: 4 75, *Includes land:0 Yes [No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number Dealer address and phone: <br /> O 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 hi court and is subject to penalty for perjury. <br /> Dealer name{print): . Dealer signature: Date: <br /> • <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> OTT ;itt-ticv uY 6 Z‘t 4-0 to U ►rn' �4 <br /> J �Lrl� c)'- 6)11 r1 <br /> X <br /> 440-2952(7117/c0M) • Page 2 <br />