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• SECTION 1 NATURE OF FILING(check all that apply) EIODZIOIXMOVICP1140C ) 0 Used home sale 0 Trip Permit BocRertifertDivixsirms lgoolatiVRVAIMW1020 _ SECTION 2 APPLICANT INFORMATION (please print) ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent El Owner/Buyer ❑Legal Representative Name: William Steven Black Phone: 503-510-3054 (first,middle,last) Address: PO Box 20112 City: Keizer State: OR ZIP: 97307 Email: wsteveblack@gmail.com SECTION.3 HOME INFORMATION (information in bold is required)' Home ID#: 337678 OR No Home 1D: ❑New Home ❑Out of state home ❑Leaving County Deed Records Manufacturer: Golden West Homes Acct#605538 Model: GE442F Year: Serial Number(s) HUD Label Number(s)*Required if new home ALB031327ORA ORE 494634 ALB031327ORB ORE 494635 #of Sections: `2, Sq.footage: 1 188 Bedrooms: 3 Bathrooms: 2 Roofing type: Comp Siding type: Lap cement Heating type: Electric Cooling type: N/A. Date of sale: 0-applicable) 4-1-22 Sale price: $1.00 Includes land: El Yes ■❑No SECTION 4 DEALER INFORMATION (leave blank if no dealer) Name: (first,middle,last) License#: Address: City: State: ZIP: Email: Phone: I hereby declare this manufactured structure is free and clear of all mortgages,deeds of trust,security interests,and liens.I have the legal right to sell this manufactured structure or my interest in it. The information listed is true to the best of my knowledge and belief,and I understand it can be used as evidence in court and is subject to a penalty of perjury. Signature: Date: SECTION 5 HOME LOCATION Current Address: 23301 Salmonberry Lane SE City: Lyons County: Marion State: OR zip: 97358 Park Name: (if applicable) ❑This is a dealer lot or storage facility El This home is being moved to a new location Complete the section below kimumtddresst came from 25685 Brush Creek Rd City: Sweet Home County: Linn State: OR zip: 97386 Park Name:(if applicable) ❑This is a dealer lot or storage facility Transporter Name: Phone: Address: City: State: Email: Page 2