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we, Act e_ Rcl) S <br /> \.) .\ <br /> SECTION 1 NATURE OF FILING(check all that`apply) <br /> 0 New home to MHODS Q°` MtHROfttelaW9MY <br /> lijodibubboaratais liaxkricalthgascrabP0Peoix wit agar <br /> ❑ Trip Permit <br /> kiodoibutOlocersmatir,kx <br /> SECTION 2 APPLICANT INFORMATION (please,print) <br /> 0 Dealer/Seller 0 Lender 0 Escrow/Title Agent 0 Owner/Buyer 0 Legal Representative <br /> Name:MATTHEW STEVENS Phone:877-522-7385 <br /> (nrsl;middle,lass} <br /> Address:2955 FIAT AVE <br /> . .. . city:SPRINGFIELD State:IL Z1P:62703: <br /> Email:DMIAGENTS@EMAILDMI,COM <br /> SECTION 3 HOME INFORMATION (Information In bold Is required) <br /> Home ID II: New OR No Homo ID: 0 Now Home Out of state home El Leaving County Deed Records <br /> Manufacturer:FLEETWOOD HOMES INC (g(j 5 a 5 5 <br /> Modol:210WV24523V Year:2023 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> FLE2100R22-22594A ORE 659295 <br /> FLE2100R22-22594E ORE 559296 <br /> #ofSections: 2 Sq.footage: 1213 Bedrooms: 3 Bathrooms:, 2.___.._-. <br /> Rooting type: ASPHALT SHINGLES Siding type: T.11MMDBOARD Heating type: FORCED AIR Cooling type: N/A'. '.. <br /> Date of sale: 05/10/2023 Snle price: 145900 Includes land: ❑Yes 0 No <br /> (lliappllrnble) <br /> SECTION'4 - DEALER INFORMATION (leave blank if no dealer) <br /> Name:AMBER HOMES LLC License#:MHFRET00037874.-• <br /> Urst, last) <br /> Address:201 SILVIA COURT <br /> City:LOS ALTOS state:CA ZIP:94024 <br /> Email: Phone: • <br /> 1 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 1 undors nd it can d s evidence in court and Is subject to a penalty of perjury. <br /> Signature' 1 �A�� / Date:06/26/2023 <br /> SECTION 5 HOME LOCATION <br /> Current Addressl#P1019WEOLiabRIPPSPAIMPS 2655 Progress Way 97071 <br /> City:836E3W Woodburn County:MARION State:OR zip:9122,6c <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: 4915 Swegle Road NE#23 <br /> City: Salem County: Marion State:OR Zip: 97301 <br /> Park Name:(if applicable) Sunset Village ❑This is a dealer lot or storage facility <br /> Transporter Name: Phone: <br /> Address: City: State: <br /> Email: <br /> Page 2 <br />