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q 53 G ry-t IOE auvwr9 <br /> SECTION.1 NATURE OF FILING (check all that apply) <br /> 0642I0DS i -owner o e: ) <br /> Used home sale KLANcirel ng re ro IS I c a-sTOTage <br /> . kl/ sebtlikstatasersitaage ovi o pe status ■❑ Trip Permit <br /> Eirvas s r tance er pje se ): <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent Owner/Buyer ❑Legal Representative <br /> Name: Vassa Sharabarin Phone: 780-623-0359 <br /> (first, middle, last) <br /> Address: 17189 Harmony Lane <br /> City: Woodburn State: OR ZIP: 97071 <br /> Email: <br /> SECTION E. ' HOME INFORMATION (information in bold is required) <br /> Home ID#: N/A OR No Home ID: ❑New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer: Skyline 6, 0B 3 D ) <br /> Model: Year: 1996 <br /> Serial Number(s) HUD Label Number(s) *Required if new home <br /> 2G910696IAB ORE 304961 <br /> #of Sections: 2 Sq.footage: 1848 Bedrooms: 3 Bathrooms: 2 <br /> Roofing type: Comp Siding type: Hardy board Heating type: Electric Cooling type: <br /> Date of sale: 10-25-2023 Sale <br /> (If(If applicable) P 0,000 Includes land: ❑Yes 0 No <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name: ' <br /> (first,middle, last) License#: _-- <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 /> SECTION.5 ' HOME LOCATION <br /> Current Address: 63 N Bear Creek Road <br /> City: Otis County: Lincoln State: OR Zip: 97368 <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> ❑This home is being moved to a new location Complete the section below <br /> New Address: r 53 7 6 r m R cI 31 <br /> City: A voLY-0 cf County:may-1Q,n State: h Zip: 9 7b <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name: Charles Thomas Phone: 541-980-5711 <br /> Address: PO Box 652 City: Lyle State: WA <br /> Email:twilson23dad@yahoo.com <br /> Page 2 . <br />