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—Fe <br /> lv c3 P pev <br /> 5 <br /> SECTION 1 NATURE OF FILING(checkallthat-apply) <br /> ]��ls io �to ODS ❑` N9rfcitiufro57577rrer D r�io 't�er e� ) . <br /> h e l �Rec din s rop ty El 6 to st e <br /> ec ' er ar g� a mg from al tus ■❑ Trip Permit <br /> [ nsfe eri s,s_ ❑rs-Qthe eas <br /> SECTION 2 °° APPLICANT INFORMATION(please print) r�` <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name: <br /> Urst,middle, last)Clayton Homes Phone:541-967-8555 <br /> Address:1437 Century Dr. NE <br /> city:Albany State:OR ZIP:97322 <br /> Email:HC613@claytonhomes.com <br /> SECTION 3 a" HOME INFORMATION (information in bold is required) `x . <br /> Home ID#: a V E vV OR No Home ID: ❑New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:Clayton Homes Albany (, b B 5 ' <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 /> afapplicable) <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer)' <br /> Name:Cla ton Homes License#:MSD195 <br /> (first,middle,last) y <br /> Address:1437 Century Dr. NE <br /> city:Albany State:OR zIP:97322 <br /> Ernaii: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 /> SECTIONS '.' 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: y co 4 68 T e per Pa rk Way A- `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 />