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• <br /> 'SECTION 1 NATURE OF FILING (check all that apply) <br /> eu m o • g �`� J <br /> •• Used hoe sale c n [ pateawitstale"- <br /> �e n i ge r -1pe atus tip Permit <br /> y inheritance [ 1tt1e/p`l�e note): <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> ❑Dealer/Seller ❑ Lender ❑ Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> • <br /> Name: <br /> (first;middle, last) S Q I \,e 54re �Ji i \e Q et )4,e r Y-t C�.11 ch - _ Phone:5 0"3 '�coq b to s <br /> Address: C/b A I. A0 U V•P Yl Ctl "7 a 5 corevne(c‘41 s 1 SE <br /> City: s i m State: O R. ZIP: q ) <br /> Email: <br /> SECTION 3 HOME INFORMATION (information in bold is required) <br /> Home ID#: 269551 OR No Home ID: ❑New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer: Fleetwood 13 <br /> Model: k)l e�, e 41 a 18.41ve8 Year: 1992 <br /> Serial Number(s) HUD Label Number(s) *Required if new home <br /> ORFLN48A14645CP ORE 223428 <br /> • <br /> #of Sections: 1 Sq.footage: 938 Bedrooms: 2 Bathrooms: 2 <br /> • Roofing type: Comp Siding type: T1-11 Heating type: Electric Cooling type: N/a <br /> Date of sale: GC5 <br /> (If-applicable) 5~ (p•a� Sale price: 30, -- Includes land: ❑Yes IS No <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name: <br /> first,middle, last) License#: <br /> Address: <br /> City: State: ZIP: • <br /> . ' • Email: Phone: <br /> I hereby declare 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 or my interest in it. The information listed is true to the best of my knowledge'and <br /> belief, and I understand it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature: Date: <br /> SECTION 5 HOME LOCATION <br /> Current Address: 10655 Wiseacre Lane NE <br /> City: Aurora County: Marion State: OR Zip: 97002 <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> ❑This home is being moved to a new location Complete the section below <br /> New Address: a l 18 T i C Z G t <br /> City: Se, )c Yt County: /lie`i State: Ole Zip: 9 730.5 <br /> Park Name: (if applicable) SI 1'3eY�DO a U a 1 1 Ci ❑This is a dealer lot or storage facility <br /> • Transporter Name: Phone: <br /> Address: City: State: <br /> • Email: • <br /> Page 2 <br />