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i 6,U/ <br /> DocuSign Envelope ID:3F08C130-636A 4D26-A8D4-ECE9B1A3ED19 4,3 6 0 a_A-5 S 4. -4 I b 4 W o <br /> SECTION 1. _ `NATURE'OF FILING(check allliat apply) ' . ' <br /> ❑ New_ho to MHODS ❑ o vi goner a on es° 1 ' <br /> F . U sale nv rage <br /> cur eret change - no A: g k o , ,.1 .tus INI Trip Permit <br /> s in rl a�li ce e; -a ): <br /> •SECTION 1 ; -. APPLICANT,INFORMATION(please print) ''" <br /> Dealer/Seller 0 Lender ❑Escrow/Title Agent , ,Owner/Buyer 0 Legal Representative <br /> Name: 1j a , j�.�,� (-torpors <br /> (first,middle,last)` �d,I1�!� Phone: ). 7_� j <br /> Address: I-/3 I fl t.�,o 11,- }r. N WW. <br /> City: 4 I bAji Li_ State: (12, ZIP: 013ae- <br /> 1 <br /> Email: <br /> SECTION 3 `, ,„' HOME INFORMATION`(Information in bold'Is required) <br /> Home ID#: OR No Home ID: KNew Home ❑Out of state home 0 Leaving County Deed Records <br /> . ..Manufacturer. % l i ii ( 'yin\f i l bu z. .. . ( (�, 1 5 a-6 . <br /> Model: 1�.. 97} Year:Dcga <br /> tt '' Serial fNumber(s) HUD Label Number(s)*Required if new home <br /> 5(1001-FAR <br /> #of Sections:. tt Sq.footage: 'CJ<D Bedrooms: D Bathrooms: <br /> Roofing type: :5+'1l1.4.k, Siding type: ((-4-,kip Heating type: 4_4 C Cooling type: <br /> te Da of sale: ` f r ` <br /> (at a tcable) Sale price: . Includes land: ❑ .Yes to <br /> SECTION 4 "' • DEALER INFORMATION'(leave blank if no dealer) <br /> Name: �.J , �' � � : �. <br /> (first middle,last) L Ci'(;�"l'' 1 �1rCS License#: <br /> Address: f L <br /> _ 0S CIari-GCrt� lV�. _ <br /> City: -1 a.ht <br /> State: 02 ZIP: Cr 739,),- <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 unc erst@.ri igrraYbe used as evidence in court and is subject to a penalty of perjury, <br /> Signature: w{ <br /> (�yy <br /> Da <br /> uoioaaE6tTaCa4Y t <br /> e 5/1/2024 <br /> _SECTION'S • , , - HOME LOCATION • <br /> Current Address:c)I4L1_5 : p k , <br /> City: J I.bin c j- County: 1 j l'}n Stater Zip:qua> <br /> Park Name:(f applicable) 0 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: . t <br /> City: 6 fn v I County: Mij- State: OQ Zip:C r 0 t l V <br /> Park Name:(if applicable) 0 This is a dealer lot or storage facility <br /> Transporter Name: ' h„� i'r ' q+-_Fj .�� v <br /> /•� ( �� ��_.�, ( Phone: �y �- lu <br /> Address: p 0 , (...,"-iC City: Char , State: P <br /> .A tt tl t <br /> Email: <br /> Page 2 <br />