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D-B TaJô r Pc, Ly 1.10n � ans 9 35 ?) <br /> 1520085 <br /> NATURE OF.FILING(check all that applies).: <br /> s c re ge ersh em i ' de • ' n: <br /> pr o a r Trip permit 0 Converted to storage <br /> • <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller ❑Lender 0 Escrow/title agent 0 Owner/buyer 0 Legal representative <br /> Name:Amy Nieto <br /> Address(including city,state,and ZIP): 11028 TAYLOR PARK LANE LYONS OR 97358 <br /> Phone: S o 4 4 7. 2CYZ <br /> Email: bi� r c. ,•• ( bk oo . <br /> HOME INFORMATION (#required) <br /> Home ID number(if known): DMV X-plate number(if known): -lam <br /> 0 Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> Other: <br /> Manufacturer:DRM561F 56 Model:72DRM28563AH23 Year:2023 <br /> Manufacturer serial number HUD number <br /> ALB042513ORAB <br /> *Number of sections: *Square footage:I *Number of bedrooms: *Number of bathrooms: <br /> *Type ofroofing:4rLL, 51„,: I *Type of siding: LP'S,.,art 4,„,tHeating: EIt,L, *Cooling: plead' Phmp <br /> *Date of sale: 5/I o/;t'-/ *Sales price: It)75 g g *Includes land: 0 Yes ®'No <br /> DEALER INFORMATION(if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR 1437 CENTURY DRIVE NE <br /> Al S ts I ci 3 ALBANY OR 97322 <br /> (541)967-8555 <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 /> I hereby declare that the above statement is true to the best of my knowledge and belief,and that I understand it <br /> is made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print): r Dealer signature: M/ Deg:litz-3 <br /> ell y+on Hoe s oP 4Ib gravy ra \� `�C/1 5 <br /> TRANSPORTER',INFORMA_," �_�N(if IYI'ot moving, leave blank). <br /> Transporter name: Transporter address and phone: (541" e 7q - 344G <br /> tnw�l4- irb.at Trwr s por-�- ?'o C5©x 8g4��1�i <br /> Gha+l o N 82. 8 g r G 1,14 <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TitleApp11211 Page 2 004741491-00001 <br />