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SECTION'1 NATURE OF FILING.(check all that apply) <br /> a New home to MHODS ❑ Adding or removing a co-owner ❑ Demolition(Date: ) <br /> 0 Used home sale • , [i Recording as real property ❑ Converted to storage <br /> ❑ Security interest change ❑ Removing from real property status 1 Trip Permit <br /> El 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: I_tne- Phone:5 p 0 2 .7 Q• <br /> d� <br /> Ursa Middle,last) <br /> Address: /o7CS Sul <br /> City: e�tea,„ State: c ZIP: 9 7,- .25- <br /> EmaiI: -ems-moo-.,•Par_kfav��o Ciq 09te.,:_4t7 _ow <br /> SECTION 3 HOME INFORMATION(information in bold is required) <br /> Home ID#: W OR No Home ID: ❑C New Home ❑Out of state home ❑Leavin+gCounty Deed,Records' <br /> Manufacturer: q�r, �{ -b or (p D 7 4 l <br /> Model: 3 10 pip teZ 3z Year: ZoZ 4 <br /> Serial Number(s) t t St!4A,-4 t3 HUD Label Number(s)*Required if new home <br /> #of Sections: 2 . Sq.footage: /gob Bedrooms: 3 Bathrooms: 2. <br /> Roofing type: yn,sL Gt\ Siding type: rjee r e a.oa.vl Heating type: cie c Cooling type: At A <br /> Date of sale: Includes land: ❑Yes No <br /> (Ifappeiaabee) ea-1,O-2 3 Sale price: /37,SS a <br /> 'SECTION 4 •DEALER INFORMATION(leave blank if no dealer) <br /> Nank. s-a...i �.,.t d b�.5he_rtaMt4e eke t onxCA ' License#:204 <br /> (first,middle.last) :,av,he.. 1N Ps r&ae 3s <br /> Address: Qi;O S E $V.Q:orlda.•. a.• <br /> City: b\ka tr 40r Or. State:0 r. ZIP: 11 Z $ <br /> Email: SCAua ict.an-i0.co ry hang;attic)&00+l .-C.pw) 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( 2tei,41.t_o_."arta- Date: 5.-3 t-2a0,14 <br /> SECTION 5 HOME LOCATION <br /> Current Address: /78 t'?. .S-f r `I <br /> • City: Sc , S QJta`\t5 hvt State: ell- Zip:173 7 <br /> Park Name:(if applicable) D 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: • <br /> City: County: State: Zip: <br /> Park Name:(if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name: Phone: <br /> Address: City: State: <br /> Email: <br /> Page 2 <br />