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. • <br /> • W4 (aU —rev pev PcJ2W2 Wag <br /> 12-�L <br /> SECTION 1 NATURE OF FILING (check all that apply) <br /> is io to ODS ❑N d 'ig go ' o-o r D t tt erg te---, ) . <br /> hle le Rec din s rop ty ❑ - to st e <br /> ec er aga e mg from al peeper status 0 Trip Permit <br /> fe eriuzg. the> ea- <br /> SECTION 2 APPLICANT.INFORMATION (please print) ;r;. <br /> El Dealer/Seller El Lender El Escrow/Title Agent El Owner/Buyer El Legal Representative <br /> Name: <br /> Cla ton Homes Phone: 41- 7- <br /> (first,middle, last) Y 5 96 8555 <br /> Address:1437 Century Dr. NE <br /> city:Albany State:OR ZIP:97322 <br /> Emaii:HC613@claytonhomes.com <br /> SECTION 3 - HOME INFORMATION (information in bold is required) <br /> Home ID#: 'V E vv OR No Home ID: El New Home El Out of state home ❑Leaving County Deed Records <br /> Manufacturer:Clayton Homes Albany (a, C) B 3(c <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: ❑Yes ❑■ No <br /> of applicable) <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name: <br /> (first,middle,last) Y se Cla ton Homes License#: <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 HOME LOCATION <br /> Current Address:2445 SW Pacific Blvd <br /> city:Albany county:Linn State:OR zip:97321 <br /> Park Name: (if applicable) El 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 p of-Palk-Way (p 4 (08 `r p per- Park. oil 7 <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 />