Laserfiche WebLink
• <br /> SECTION:1 `- NATURE OF FILING(check all that apply) <br /> IDpNoutiiirmainkixtoift& ®xIttrAtxtrixp mimggf 2S tnictut li xiaemiiitiussoputxxx <br /> Used home sale Rxikitaorlinecasmettkiaarrzty gxfriacuca>timirto®temps <br /> D•x8252tMty4PattgrittifPg adtammingcfrenspecalxpanpervoymatos ! Trip Permit <br /> goacmonala#wyit Xrit5W.XX c❑i x>atht! 9IciElnolatot$xx <br /> SECTION 2 . APPLICANT INFORMATION"(Please prtnt).. <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent k Owner/Buyer ❑Legal Representative <br /> Name" Phone:. <br /> (r,st;ntcddle lush SEM 7..4A) �q)( �Aa#M/6020 SQ3'-2O 8,0e <br /> :Address'/d'Qs5 Ot q /Y -dn1 �4 /o S;i.: <br /> City:x S-1 y710 41 State: 'Q Z IP : e'-23 9 <br /> I tiiat•, , t. m4v t1VJ.c'.U/h <br /> SECTION 3 HOME INFORMATION(information in bold Is:required) <br /> Home ID#: 290153 OR No Home ID: D New Home Clout ofstate home ❑Leaving County Deed Records <br /> Manufacturer: Skyline ACCT#321147 <br /> Model: Year: 1998 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> 21910649KA <br /> 21910649KB <br /> } <br /> #of Sections: 2 Sq.footage: 1232 Bedrooms: 3 . Bathrooms: 2 <br /> g t)p COMP Sidin= e !1�t R9 i ,Heating type' �t1- pump Cooling t}}e N Pump <br /> �lt�ofm e:�� �,13`h . <br /> Pate of sale: <br /> afappit able) 7'� Sale price: LdS)66 t3 Includes land: ❑Yes (> No <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name: License <br /> (first,middle,last) <br /> Address: <br /> City: State: ZIP: <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 /> SECTIONS HOME LOCATION <br /> Current Address: Was at: 22885 North Fork Road <br /> City:Lyons County: Marion State: OR Zip:973 . <br /> Park Name:(if applicable) ❑This is a dealer lot or storage facility <br /> ,t This home is being moved to a new location Complete the section below <br /> New Address: /V613 Oki Mehama Road SE <br /> City: Stayton County: Marion State: OR Zip: 97383 <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 />