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• 3 1 1 Oi- ci-or Po R d 38 I vev-tt51-) <br /> NATURE.:OF-FILANd..(the:ck I - <br /> El New home to MHODS 1.2VA0avfekvAipmet53GAner lEADniattkvfrgesz-n__) <br /> ‘,KhifIVIkbate'Saise \,iiaotartils.rfkb0s- party 'Q't-K-Jut recrib-st5i7aie <br /> p tus [ ] Trip Permit <br /> III2N.TeSN,fensytfilvjitaue INdippeVeverARK\.,. <br /> SECTION 2 APPLICANT INFORMATION(please print) <br /> E Dealer/Seller 11]Lender 0 Escrow/Title Agent LI Owner/Buyer El Legal Representative <br /> (first,nziddNle,a im„ej ADV ANCED HOME BROKERS, INC. Phone:503-650-0304 <br /> Address:10762 S.E. HWY. 212 <br /> City:CLACKAMAS State:OREGON ZIP:97015 <br /> Email:jOhllabfahaM1958@gmail.com <br /> SECTION 3 ,,117101WE INFORMATION(information in bold is required)Home ID ID#14 ej -4 0 9‘ OR No Home ID: 0 New Home 1=1Out of state home DLeaving County Deed Records <br /> Manufacturer:PALM HARBOR - 513,1•3 <br /> Model:UNKNOWN Year:2001 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> PH204717 ORE 415880 <br /> PH204717 ORE 415881 <br /> PH204717 ORE 415882 <br /> of Sections: 3 Sq.footage: 2055 Bedrooms: 4 Bathrooms: 2 <br /> Roofing type: COMP Siding type: T-1-11 Heating type: ELECTRIC Cooling type: NONE <br /> Date of sale: 07-15-23 Sale price: $59,950.00 Includes land: LIYes E No <br /> afapplicable) <br /> SECTION 4 • 1: -DEALER INFORMATION(leave blank if nO dealer) <br /> (first,middleName:IasiADVANCED HOME BROKERS, INC. License 4:MSD-579 <br /> , ) <br /> Address:10762 S.E. HWY. 212 <br /> City:CLACKAMAS State:OREGON Z1P:97015 <br /> Emaii:johnabraham1958@gmail.com Phone:503-650-0304 <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 rnAnufacture;I strture or my interest in it.The information listed is true,to the best of my knowledge and <br /> belief,and I understandlt can be u,Sed/as7vidence in court and is subject to a penalty of perjury. <br /> Signature: • 1 / ; Date: it131,2/0 <br /> 7 7 LOCATION • • <br /> Current Address:12604 REO RD.S.E. <br /> City:RAINIER County:THURSTON State:WA. I Zip:98576 <br /> Park Name:(if applicable) 0 This is a dealer lot or storage facility <br /> El This home is being moved to a new location Complete the section below <br /> New Address:3871 VICTOR POINT RD. N.E. <br /> City:SILVERTON County:MARION State:OR. Zip:97381 <br /> Park Name:(if applicable) fl This is a dealer lot or storage facility <br /> Transporter Name:CT WILSON Phone: 541-980-5711 <br /> Address:PO BOX 652 City: LYLE State: WA. <br /> Email: <br /> Page 2 <br />