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SECTION 1 NATURE OF FILING (check all that apply) <br /> [t]i., w iktatj'IdOVS Adtil}t pr-kpitiviNAgo,gwner EI-14 Jitiji' te: <br /> 0 Used home sale jtt 'rs.i°ealy t c, M\Ckve4Atol4Prage <br /> o ange jf Removing from real property status 0 Trip Permit <br /> [Nl a er 'kinhcritkce aieRteVii14006A <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent 0 Owner/Buyer ❑Legal Representative <br /> Name: Steven Domogalla • Phone:5(3 q4q-78b5 <br /> (first,middle, last) <br /> Address: 8490 Aumsville Hwy SE <br /> City: Salem State: OR ZIP: 97301 <br /> Email: c oryn C) Cct t I cks m n i <br /> SECTION 3 ' HOME INFORMATION (information in bold is required) <br /> Home ID#:J1j • OR No Home ID: ❑New Home ❑Out of state home El Leaving County Deed Records <br /> Manufacturer: Fleetwood Acct#134423(530303) <br /> Model: Barrington Year: 1983 <br /> Serial Number(s) HUD Label Number(s) *Required if new home . <br /> WAFL2ABD15314559 <br /> #of Sections: 2 Sq.footage: 1790 Bedrooms: 3 Bathrooms: 2 <br /> -Roofing type: Comp Siding type: T1-11 Heating type: Heat pump •Cooling type: Heat pump <br /> Date of sale: a /i� Iay <br /> Sale price: $5,000.00 Includes land: ❑Yes. 0 No <br /> gapplicable) 9 <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name: License#: <br /> (first, middle, last) <br /> Address: A.//t) @7 '& <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 /> SECTION 5 HOME LOCATION <br /> Current Address: 8490 Aumsville Highway SE <br /> City: Salem County: Marion State: OR Zip: 97317 <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: 9223 55th Avenue <br /> City: Turner County: Marion State: OR Zip: 97392 <br /> Park Name: (if applicable) El This is a dealer lotor storage facility <br /> Transporter Name: v eij, trek,u.5 -T-I-L zA!C'.a� 1. C. , Phone: S 7 I '� '—Ty/c1 <br /> Address: 5--/Sic ky ri g� 7 City: ts e_'j State: g_ <br /> Email: • ,Slrtek.kkG`ri krlV y&hrl t?r'�, e- <br /> Page 2 <br />