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<br /> 2`1 -1 (J O .N 0 VIA1 Sco-v\--c e .Im )4‘,0\, cs ., ni: n c, 1_,./ ,: . • .!
<br /> •
<br /> SECTION 1 . • NATURE OF FILING (check all that apply)
<br /> ' ti, S A in�� r r t r BI,DIVO0iiticattlatc, )
<br /> Used home sale Z, l . ` deg -
<br /> Se sity*iuterest_chuge Removing from real property statusTtip Permit
<br /> .. .. • ' cr icy irthefitaace Other(please note):MOVING OUT OF CLACKAMAS COUNTY -
<br /> SECTION 2 : ,_ APPLICANT INFORMATION (please.print) -- ... .: _ ...- .
<br /> - .0-Dealer/Seller ❑ Lender ❑ Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative
<br /> .Name. Phone
<br /> (first middle last) Ht_ o P , .., Pfz,,L- �r �+
<br /> ,t,t .� C .��5t-Ni .:-(so c. g-1 t ►•`lt''S
<br /> Address: ,,D-t-1,49-, S 1-..,10wL5,_ ,U 32,CA.:-)t_ 21>
<br /> City: t~-t .,a�..�.o. State: ZIP: �j.p .
<br /> Email: p,-1t_Hn,tS4-, C-,r-t�,L. . car-1
<br /> SECTION 3 HOME INFORMATION (information in„bold is required)
<br /> Home ID it: %0y s S t OR No Home ID: E New Home ❑Out of state home teaving County.Deed Records
<br /> Manufacturer: t.-t.,,a___A__L-ram +--tom,-11.-- - "-lc-- - . .
<br /> Model: Year: t`1�1 -1 • -
<br /> °D 2��t
<br /> Serial Numbers) HUD Label Number(s) '`Required if new home ..
<br /> ;M of'Sections:;-• 2. ,' .Sq.footage: t l c%'(---' Bedrooms: Bathrooms: Z
<br /> Roofing type l. Siding type: " /t 1 Heating type: Lie.. 1-si - . Cooling type '-•f ezr ,t._`
<br /> :.�Date.of sale: --Z Sale price: ,c'e' Includes land: El Yes lo ; :
<br /> (If applicable)
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<br /> SECTION 4 . - : -. DEALER INFORMATION (leave blank if.no dealer): ..
<br /> Name: License 1': • _.
<br /> (frst,middle. last)
<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 /> :SEC°TION 5 HOMEELOCATION .
<br /> ,Current Address: 377'/g S, N01„,71605 t2 c Rot,
<br /> City: /1.0,010\ County: CIACke,ena5 State: '0 Zip: 61708
<br /> Park Nance: (if applicable) ❑This is a dealer lot or storage'faciliiy
<br /> ®This home is being moved to a new location Complete the section below
<br /> New Address: 27760 A) coll+iaen 1 '
<br /> City: /l t 11 411",
<br /> County: C'Ct i.O" State: 0?.- Zip: 9736n.
<br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility
<br /> Transporter Name: 1 -f- j rinCk.t‘,7? Phone: SyJ -2/3 - isf�t
<br /> Address: S27 • AN E Iwl Ave- S1E 3 City: .('.tk. onr7. State: 07... . , - - .
<br /> Email: o.'�Itil A.Ci.Lk',"t5 SYl0 6'r`'00 1• ai,-\
<br /> Page 2
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