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<br /> 7/31/2024 5:26 PM FROM: Office Depot 112309 TO: +15039172333 P. 2 •
<br /> SECTION 1 • NATURE OF FILING(check all that apply) . •
<br /> DS Cdtiing rim anptrED.Qwner �l�e nolrliCls-C 1 ,,,F,,,., )
<br /> 54..Used home sale �ed-tov`enage_
<br /> e e n ro arty status (S..Trip Permit
<br /> r will.' a tker Veas no : • I ' '
<br /> SECTION 2. APPLICANT INFORMATION (please print)
<br /> . •• •• . 0 Dealer/Seller 0 Lender 0 Escrow/Title Agent
<br /> g lig Owner/Buyer 0 Legal Representative':....: ,:,..;:::-.
<br /> .AV• ' "Name .
<br /> ,middle,Iasi) fl i1 h44T .. 170..v-1 art r✓ 0m5e✓1..t • •• Phone:SO' •.S..$ -`4a'7
<br /> .Address: a405- K,k.1 Aril ct, ,e.j v c.v.- P ti)r . • .. _ . ...........
<br /> City: K A (u m c:.J 1State: w4 ZIP: '�g 6-...:_......
<br /> Email: a.4tn.a4-4' c r A.m S ,a t..{.I- at. �tweu. aer rrl .
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<br /> SECTION 3 HOME INFORMATION (Information In bold Is required) •
<br /> ... .. . : . •
<br /> Home 1D#: Z'La 41-7 OR No Home ID: ❑New Home _
<br /> ❑Out of state home�Leaving County Deed Records .
<br /> Manufacturer: G,:bcs I . • I a 'I.C9 a J
<br /> Model: UA4 r1•LionYear: 1 it,•
<br /> • Serial Number(s) . . HUD Label Numbers)*Required ifjnew'home
<br /> ti X7244401a 1,1,4"Lkh,0„9►1
<br /> T ^
<br /> #of Sections: ..•- , )L• _ Sq.footage: '2 . Bedroorgs: g lll:athroonis:, .. ^,. •,� ,• :1
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<br /> Roofing. :type: ¢- w:� Siding type: kI��,y�' Heating type: j jet.4;r}.4,,Cooling ty`per:_k0a(h;ii;.A:
<br /> Date of sale:
<br /> p�of plleablP) • Sale price: Includes lands. []Yes- INNo •
<br />, .SECTION 4 . . •DEALER INFORMATION(leave blank if no dealer) • , " _ ,
<br /> - Name: �], License#�
<br /> (firs!:ririrldle,Iasi) JN' R7 i .. '
<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 ilia
<br /> legal right to sell this manufactured structure or my interest in it. The information listed is true to the best of my knowledge a nd
<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: I 013 'Fern Rily a Rd.
<br /> • City: :(yyfoh i County: /irriora State: DR Zip:q7,g.3
<br /> Park Name:(•applicable) 0 This is a dealer lot or storage facility
<br /> This home is being moved to a new location complete the section below 1
<br /> • • New Address: j11L kl,-e,ctdi� Lam
<br /> . City: Lain yi,uy County:edrto-fi`f- State: 14q Zip; 9 p 4,.32.
<br /> Park Name:(if applicable) rJ 0 This is a dealer lot or storage facility
<br /> Transporter Name: (. - • wi j,,n heq,N.ra t^-f _ Phone:,4 / - %go - 7ji
<br /> Address: '• ' fg,?t G) '2. My; 2�! e. StSAR gd La,�"•
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<br /> Email: 7 W I /.3 v'7 oL� •I'4C'c.Q (f ,r �.:r,. G-�-' I
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<br /> Pacm7
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