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Ca � p€v PcW ))2., °?•e_ c <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> ■ o ‘to ODS N d 4 N9tfoiriufrc-07707rrer D o ) <br /> h e le Rec din s rop ❑ • to st e <br /> ec ' er ng e mg from al of St status ❑■ Trip Permit <br /> fe eri e th please ) <br /> SECTION 2 APPLICANT INFORMATION (please.print) 5 <br /> El Dealer/Seller El Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name:Cla ton Homes Phone:541-967-8555 <br /> (first,middle,last) y <br /> Address:1437 Century Dr. NE <br /> city:Albany State:OR ZIP:97322 <br /> Emall:HC613@claytonhomes.com <br /> SECTION 3 "; HOME INFORMATION (information in bold is required) <br /> Home ID#: +V E v J OR No Home ID: El New Home El Out of state home El Leaving County Deed Records <br /> Manufacturer:Clayton Homes Albany £! b g v <br /> Model:Tempo Under Pressure Year:2023 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> ALB0430340RAB NTA2210947 <br /> NTA2210948 <br /> #of Sections: 2 Sq.footage: 1,280 Bedrooms: 3 Bathrooms: 2 <br /> Roofing type: Arch Siding type: Smart Pan Heating type: Electric Cooling type: <br /> Date of sale: 12/15/23 Sale price: Includes land: [1]Yes II No <br /> of applicable) <br /> SECTION 4 -: _ DEALER INFORMATION (leave blank.ifno dealer) . <br /> Name:Cla ton Homes License#:MSD195 <br /> Urst,middle,last) y <br /> Address:1437 Century Dr. NE <br /> city:Albany State:OR ZIP:97322 <br /> Email:HC613@claytonhomes.com Phone:541-967-8555 <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 :w' r <br /> HOME LOCATION <br /> Current Address:2445 SW Pacific Blvd <br /> city:Albany County:Linn State:OR Zip:97321 <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 4--Teppel-Pafk-Way (.o 4 („28 —ref re, Pa ri4. Way <br /> City:Keizer county:Marion State:OR Zip:97303 <br /> Park Name: (if applicable) Stadium Village ❑This is a dealer lot or storage facility <br /> Transporter Name:Bennett Trucking Phone: 541-879-3444 <br /> Address:PO Box 100005 city: McDonough State: GA <br /> Email: <br /> Page 2 <br />