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• 11 eibiF Chub d cl'13?5 <br /> SECTION:1 .NATURE OF FILING(check ali that apply). <br /> ® New home to NIHODS ❑ Adding or removing a co-owner ❑ Demolition(Date: ) <br /> ❑ Used home sale _ ❑ Recording as real property ❑ Converted to storage <br /> ❑ Security interest change ❑ Removing from real property status ,Trip Permit <br /> ❑ Transfer by inheritance ❑ Other(please note): <br /> SECTION,2 _'APPLICANT INFORMATION (please print) <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent ®Owner/Buyer ❑Legal Representative <br /> Name: Phone:/ 0 Sol-��9 <br /> first middle, last) �eY'�-t1� ��Y�� �('G��ri»v4 -'(��. <br /> Address: I l aaa. -3-AGs.sovx 901E S 4,3)1) <br /> City: 7e-c tsar State: ZIP: 9136' <br /> Email: —.Se,r,e`• rtk\e-P..\:•,‘ 5 6 NO'"1MeA I -C��, <br /> SECTION.3 HOME.INFORMA <br /> TION`(information in bold.isregti redj � 03.5 Home ID#: N,eo OR No Home ID: ❑New Home Out of state home ❑Leaving County Deed Records <br /> i <br /> Manufacturer: L <br /> Model: 1 LI ( ( Year: (C <br /> ccil <br /> Serial Number(s) HUD Label Number(s) *Required if new home <br /> 09(Q3'S'O 1, - OR.5 3166 <br /> #of Sections: I Sq.footage: 508() Bedrooms: 'S Bathrooms: 02 <br /> Roofing type: ovn 9 Siding type: Heating type: I e��rc L Cooling type: flunk <br /> Date of sale: <br /> (Ifapplicable) I I ill fa z1 Sale price: 4,-10 0 Includes land: ❑Yes IX No <br /> SECTION.4 DEALER INFORMATION_(leave blank;if no dealer) <br /> Name: 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: k 011S \lack\A kve <br /> City: oG2 Tevc County:?ee;C State: \,\IR Zip:et(8 ,9O <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: 9 2-7 Li GL`c C(`, - -70 <br /> City: c,01,.N.o n County:Mea,6 Uv\ State: 0'Q\ Zip:9,''5 R 3 <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name: S u tes;O r Owes Phone: SLI 3 1.1 , d 5 <br /> Address: t I)t � s e yC},� � il City: C�'.-ei5 k,n State:Q� <br /> Email: 3ecr' C7Yw� l`1 � 3 OVult- n.A.:1 .cev-'1 <br /> Page 2 <br />