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: \ 59DW34-arc)K <br /> L <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> ❑ New home to MHODS avhddirwarzorocariaigaxasiwzoor aoRotogitii6gokikiO4 <br /> ElkoSparillointeccsboixaDgtx &ocRecanamingnonzaaakpvcgamagcstztus Trip Permit <br /> o e&dae 1 <br /> SECTION 2 APPLICANT INFORMATION(please print) <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent ®Owner/Buyer ❑Legal Representative <br /> m <br /> Ws!:t,middlNae,laslJe: 1-1 A • 17-1- --,` -- Phone: Ljt33 50 r3i �} y� <br /> 7 M <br /> City: +j - State: ;ZIP: 61.7 3p,3 <br /> Email: <br /> SECTION 3 HOME INFORMATION,(Information In bold is required) <br /> Home ID#: Zr'1c:, 3c OR No Home ID: 0 New Home ❑Out of state home❑Leaving County Deed Records <br /> Manufaeturer:` tap' a\i) L1)114 sreryp Co I1(65 <br /> Model: ‘.1 c47 Year: 19 <br /> •Sepal Numbers)` HUD label Number(s):*Required if newhome• <br /> #of.Sections:', . 1 Sq.footage: 4.ao Bedrooms: k Bathrooms: I <br /> Roofing type: .C �1�' Siding type: 4,46,4747T. Heating type:`, DINA f Cooling'type:.roAii<rc. f )P. <br /> Date of sale: <br /> afapplicable) %)1 1-2z2G Sale price:, s"ecc,0 Includes land: 0 Yes )2: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 /> 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:: 5010 •3W?e. <br /> City: S ~('O, 'County: �- State: Zi <br /> mil- � MVO- DV_ - p:, i.75e3 <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: 1590 N 3rd Avenue <br /> City: Stayton County:Marion State: OR Zip: 97383 <br /> Park Name:(if applicable) Zdc This is a dealer lot or storage facility <br /> ,Transporter Name,, a c jt,;(ti, �j � a0 Phonef 503 <br /> Address: -)'"t-l' yoi � go City: A� 0 i State:' cxte <br /> Email: ''MA1,1 c2"kt� itl, JL� <br /> Page 2 <br />