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• Aa c\ f? sk- <br /> y v <br /> NATURE OF FILING (check all that applies) <br /> i gg�s esitiirfaerest ["Change ownership o ' o m i . <br /> g ro • m 'Trip permit '©Ao6 t st rge <br /> r <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller 0 Lender ❑Escrow/title agent [ Owner/b_mgr_ 0 Legal representative <br /> Nam6: IN i I:t,S11(1vNTS. l.1,c, Ceti CA-2P <br /> Address(including city,state,and ZIP): 1-(0 45- lu t-LAr(L OLL P-A) /S Sittgr 1, �.Z.3_02,:,; <br /> :Phone: ._Su3-- e6k . Vcc, <br /> Email: 5 51 L, ,A'ot- <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 4O( ,5� <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: 0 Coming out of county deed records <br /> ❑Other: f S eGr el-evve <br /> Manufacturer Model: 3 I o il r>20,o 3 c Year: 2016, <br /> Manufacturer serial number HUD number <br /> l�N143)0gib IiCi4q A <br /> PN 310 i L l:ig49 <br /> • <br /> *Number of sections: .2 *Square footage:/(026 *Number of bedrooms: 3 *Number of bathrooms: . <br /> *Type of roofing: Shiny'tr *Type of siding: *Heating: FW eel./5' ' *Cooling: ---- <br /> *Date of sale: t 2 -1 S-20'L L. *Sales price: 4 75, *Includes land:0 Yes 0'No <br /> DEALER INFORMATION (If no dealer, leave blank) <br /> Dealer name: Dealer license number Dealer address and phone: <br /> 0 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 belied:,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 /> /TM 1 2v c g-I'Y 1, Z ti of l 114N Orn' P-(3 �( <br /> Kri a:CA- - � �'4 k 1 <br /> v <br /> 440-2952(7n71COM) Page 2 <br />