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Taa � Pcr)2 Ln SE_rLyan 5 9 -73 1520085 NATURE OF-FILING.(check all that applies); • s c re ge ersh de n: nW s r p o ' a e ,y,�tatus Trip permit I❑Converted to storage WJ" "� • APPLICANT.I N FORMATION Dealer/seller Lender Escrow/title agent Owner/buyer ❑Legal representative ❑ ❑ ❑ g ❑ y Name:Amy Nieto Address(including city,state,and ZIP): 11028 TAYLOR PARK LANE LYONS OR 97358 Phone: S 0 V c2 3 St o gy Email 6,l,,t.�,. or e_..��. yI4I'+ao . (.orv%, HOME INFORMATION r required) Home ID number(if known): DMV X-plate number(if known): , (40 0 F35 0 Moving in from another state Has no home ID or X-plate because: El Coming out of county deed records ❑Other: Manufacturer:DRM561F 56 Model:72DRM28563AH23 Year:2023 .. r Manufacturer serial number " HUD number ALB042513ORAB *Number of sections: *Square footage:lc l!, *Number of bedrooms: *Number of bathrooms: *Type of roofing:Q,L.l., .S1,' *Type of siding: (, 5m At1 PA„,(Heating: E I� t *Cooling: lj eat Km?, *Date of sale: 5/I G/ *Sales price: .8)75' g g *Includes land: ❑Yes No DEALER INFORMATION (if no dealer, leave blank) Dealer name: Dealer license number: Dealer address and phone: CLAYTON HOMES ALBANY,OR /�i S i 1437 CENTURY DRIVE NE ci ALBANY OR 97322 (541)967-8555 ❑This manufactured structure is free and clear of all mortgages,deeds of trust,security interests,and liens.I have the legal right to sell this manufactured structure. I hereby declare that the above statement is true to the best of my knowledge and belief,and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Dealer name(print): Dealer signature: Dal: 16L4 y fo.„ Homes oC .Qlb av1y I-\C �,t I 2.3 TRANSPORTER'INFORMA `N (if ifot moving, leave blank) ., Transporter name: Transporter address and phone: (S4t') 879 - 3 b y �ter,�y�, - Yr�.c.�. Try, porgy ?'0 3osr ��G��t�i Glaa,4 6 t• e.j N 8.2. 6-1q 440-2952(7/19/COM) OR Title Application-10/2019-TitleApp11211 Page 2 004741491-00001