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a Paik <br /> 0 <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> 0■ New home to MHODS d ' g re o ' er ) <br /> y��,�,�_. <br /> tc h�� c e <br /> c e ctartge e g m tus ❑■ Trip Permit <br /> NVT.rafftytilicti.Nme N#1 }d r a : <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> 0 Dealer/Seller ❑Lender El Escrow/Title Agent El OwnerBuyer 0 Legal Representative <br /> Name:HOMES DIRECT OF OREGON LLC Phone:541-928-2083 <br /> Urst,middle,last) <br /> Address:3838 PALM HARBOR DR NE <br /> City:MILLERSBURG State:OR ZIP:97321 <br /> Email:TANYA.ABAD I LLA@HOM ES.D I RECT <br /> SECTION 3 HOME INFORMATION (information in bold is required) <br /> Home ID#: V v OR No Home ID: 0 New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:PALM HARBOR �j q� (a()859 a (540Tol� <br /> Model: 5t C 1-�F/S /4,0_ lam Year: <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> 12)4 3 ©CV-3 Der- s�a3q/ <br /> #of Sections: / Sq.footage: //s) Bedrooms: o_ Bathrooms: <br /> Roofing type: A Siding type: Fbe ( gin Heating type: ELECTRIC Cooling type: NONE <br /> Date of sale: 1 Sale rice: �"/ Q �/ Includes land: ❑Yes ❑■ No <br /> al-applicable) l� J�o J Saleprice: 75 O <br /> SECTION 4 DEALER INFORMATION(leave blank if no dealer) <br /> Name:HOMES DIRECT OF OREGON LLC License#:MSD 523 <br /> (first,middle,last) <br /> Address:3838 PALM HARBOR DR NE <br /> City:MILLERSBURG State:OR ZIP:97321 <br /> Email:TANYA.ABAD I LLA@HOM ES.D I RECT Phone:541-928-2083 <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 u ed as evidence in court and is subject to a penalty of perjury. <br /> Signa Date: /f,3j(/ <br /> SECTION HOME LOCATION <br /> Current Address:3838 PALM HARBOR DR NE <br /> City:MILLERSBURG County:LINN State:OR zip:97321 <br /> Park Name: (if applicable) ❑■ This is a dealer lot or storage facility <br /> 0 This home is being moved to a new location Complete the section below <br /> New Address: 57 g 71y/ OR. Piegg 4 <br /> City: )!`'iOIJS County: m K pr-) State: OR Zip: 9 <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name:BENNETT TRUCKING & TRANSPORT Phone: 541-879-3444 <br /> Address:409 BIGHAM BROWN RD City: EAGLE PT State: OR 97524 <br /> Email:YOR@BENNETTIG.COM <br /> Page 2 <br />