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1q531 Gr m Rd 10 . aut vo y-9 <br /> SECTION 1. NATURE OF FILING (check all that apply) <br /> N 108.11 t IODS i -owner RD Olxr •ffooi, e: .. . ) . <br /> El Used home sale Kinetoki ng re ro o e o ge <br /> Lit,ee b ure srs iapge ovi o pe status ■❑ Trip Permit <br /> s r •tance er setr" ete): <br /> SECTION 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 3: HOME INFORMATION (information in bold is required) <br /> Home ID#: N/A OR No Home ID: ❑New Home 0 Out of state home 0 Leaving County Deed Records <br /> Manufacturer: Skyline (0 0 B 3 <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 rice: , <br /> (If applicable) P 0 000 Includes land: ❑Yes ❑■ No <br /> SECTION,4 DEALER INFORMATION (leave blank if no dealer)- <br /> Name: . <br /> 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 /> 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: I S GJ , G i re1 R a SE . <br /> City: • lt,Y(a 1P- County:mGa,y'y4,n State: 0 c Zip: 9 <br /> Park Name: (if applicable) 0 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 />