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SECTION 1 NATURE OF FILING (check all that apply) <br /> "( ii ao,Pa1I 1S - er mat.:-- <br /> crUeNuwiluda VIV c r ' g a re3le y n, ed Mtge <br /> ut' m e ckange m g r p e tatus 717-rn; Q ,n.1 -.— <br /> anb 0 Other(please note): Given to me by brother-in-law T <br /> SECTION 2 . APPLICANT INFORMATION (please print) <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent Owner/Buyer ❑Legal Representative <br /> Name:Urst,middle, last) Jay Hyslop Phone: 503-873-3515 <br /> Address: PO Box 1357 <br /> City: Orofino State: ID ZIP: 83544 <br /> Email: kee, a ke ve kAOa C6n'1 <br /> SECTION 3` HOME INFORMATION (information inbold is required) _, <br /> Home ID#: N Jf- OR No Home ID: ❑New Home El Out of state home ❑Leaving County Deed Records <br /> Manufacturer: RODAR ACCT #322396 <br /> Model: Year: 1962 <br /> Serial Number(s) HUD Label Number(s) *Required if new home <br /> S1956 <br /> #of Sections: 1 Sq.footage: 550 Bedrooms: 2 Bathrooms: •1 <br /> Roofing type: Metal Siding type: Metal Heating type: Electric Cooling type:- N/A <br /> Date of sale: 01 <br /> ( of sale) _1 s`q9 Sale price: N/A Includes'land: ❑Yes ❑■ No • <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name: <br /> (first,middle, last) License#: <br /> Address: <br /> City: State: ZIP: <br /> • <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: 21047 Hazelnut Ridge Road NE <br /> City: Scotts Mills County: Marion ' State: OR Zip: 97375 <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: <br /> City: County: State: Zip: <br /> Park Name: (f applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name: Phone: <br /> Address: City: State: <br /> Email: <br /> Page 2 <br />