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` -0 <br /> M6V WL1 WIT1M 41bb (De 'PG <br /> SECTION1 NAAIRR OP FACING(thetit AO* . • <br /> 1-1-.3N-krestlare,GIVIITODS ERIAdaitkePlehlovihgAreQ2mIaler G' 1i s r(Bate: <br /> ® Used home sale is ge <br /> tl'/§etigk ge 7 Thp Permit <br /> 42,1znaigetibirtheritarce t . <br /> SECTION 2 APPLICANT INFORMATION'(please print):.: ::.: ::. ` . `. <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent ®Owner/Buyer ❑Legal Representative <br /> Name:Lorica Diane Bielemeier Phone:503-508-9355 <br /> (first,middle,last) <br /> Address:6888 indigo St. NE <br /> City:Salem State:OR ZIP:97305 <br /> Emollorica_b@Msn.com <br /> SECTION 3 HOME INFORMATION(information le bold is required) <br /> Home ID#:392400 OR No Home ID: ❑New Home ❑Out of state home 0 Leaving County Deed Records <br /> Manufacturer:Skyline Homes S 'i 0- <br /> Model:Ramada Value 9214CT Year:2016 <br /> Serial Numbers) HUD Label Numbers)*Required if new home <br /> KL91-0334-I-B ORE 531008 <br /> KL 91-0334-i-A ORE 531009 <br /> #of Sections: 2 Sq.footage: 1 248 Bedrooms: 3 Bathrooms: 2 <br /> Roofing type: Arch.Comp. Siding type: Hardi-Panel Heating type: Electric .cooling type: Electric <br /> Date of sale:(Ijapp7uxibie) -?-3 sale price: $70,000 Includes land: ❑Yes ®No <br /> /" `� <br /> „EECTIO 4 • DEALER INFORMATION(leave blank if no dealer). <br /> Name: License#: <br /> (first,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 /> SECI ION HOME LOCATION <br /> Current Address:6888 Indigo St. NEE 1.a n J etc. ar)cI v,.s5 <br /> city:Salem County:Marion State:OR zip:97305 <br /> Park Name:(if applicable) 0 This is a dealer lot or storage facility <br /> in This home is being moved to a new location Complete the section below <br /> New Address:4100 60th Ave NE <br /> City:Salem eounty:Marion state:OR zip:97305 <br /> Park Name:(if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name:Phil Sterling Home Service Inc. Phone:503-932-2629 <br /> Address:17225 Beck Rd City: Dallas state:OR <br /> Email:n/a <br /> Page 2 <br />