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4;nct AVe scf,lexyt <br /> Authentisign ID:5EC2930E-2D90-EF11-8473-002248299057 <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> ❑■ New home to MHODS er o Date: <br /> RAsaifoilgYAlle r rty EaVldAostsrage • <br /> nriNifi`toft/abuisge o s 0• Trip Permit <br /> NATaislaqvitziaozitence NtellitalciEaxPirttate): <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> Q Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name:COMMONWEALTH HOMEOWNER SERVICES Phone:503-244-2300 <br /> (Just,middle,last) <br /> Address:18150 SW BOONES FERRY ROAD <br /> City:PORTLAND State:OR ZIP:97224 <br /> Email:M ELISA.COOK@C W RES.CO M <br /> SECTION'3 - HOME INFORMATION (information in bold is required) <br /> Home ID#: N E. A OR No Home ID: Q New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:CLAYTON 67 fQ 6 ! 3 S <br /> Mode1:72DRM28523AH24 Year:2024 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> AL20436600RA ORE 565002 <br /> ALB043660ORB ORE 565003 <br /> #of Sections: 2 Sq.footage: 1296 Bedrooms: 2 Bathrooms: 2 <br /> Roofing type: COMP- Siding type: LAP CEMENT Heating type: ELECTRIC Cooling type: NONE <br /> Date of sale: rice: -� Includes land: Yes <br /> (IjapplicableJ Sale'a�" t P �\1C� :l`.� ❑ ❑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:2445 PACIFIC BLVD SW <br /> City:ALBANY County:LINN State:OR Zip:97321 <br /> Park Name:(if applicable) 0 This is a dealer lot or storage facility <br /> 0 This home is being moved to a new location Complete the section below <br /> New Address:2232 42ND AVENUE SE,SP.#116 <br /> City:SALEM County:MARION State:OR Zip:97317 <br /> Park Name: (if applicable) SUNDIAL MHP 0 This is a dealer lot or storage facility <br /> Transporter Name:NEWMAN'S MOBILE HOME TRANSPORT Phone:503-932-5142 <br /> Address:PO BOX 236 City:SILVERTON State:OR <br /> Email: <br /> Page 2 <br />