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Authentisign ID:60E8CAC3-93C1-EF11-88CF-002246299057 '41 8 8,,D, kancas,v C R i E <br /> SCUle--1111 <br /> ECTION 1 NATURE,OF FILING,(check all thatapply) <br /> I New home to MHODS F 6g ofVAavitirfriokl ier <br /> Wtbakkallaesate felt/srofSituOasiedl‘pr i-ty nAct:Slorettp&testorage <br /> e t i'tstAtefat oinfji ge e a ❑� Trip Permit <br /> aW(y(t h rt(epeg ndease eee): <br /> ;SECTION 2 APPLICA'NT INFORMATION (please print) <br /> ❑■ Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name:COMMONWEALTH HOMEOWNER SERVICES Phone:503-244-2300 <br /> (first,middle, last) <br /> Address:18150 SW BOONES FERRY ROAD <br /> City:PORTLAND State:OR ZIP:97224 <br /> Email:M ELISA.COOK@CW RES.COM <br /> SECTION 3 = HOME.INFORMATION,(information in bold is required) > <br /> Home ID#: OR No Home ID: ❑■ New Home ❑Out of state home ❑ Leaving County Deed Records <br /> Manufacturer:PALM HARBOR <br /> Mode1310AF14371 C Year:2025 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> PHH3100R24-16133A ORE 564607 <br /> #of Sections: 1 Sq.footage: 503 Bedrooms: 1 Bathrooms: 1 <br /> Roofing type: COMP Siding type: FIBERCEMENT Heating type: ELECTRIC Cooling type: NONE <br /> Date of sale: 9-25-24 Sale price: $59,402 Includes land: ❑Yes No <br /> of applicable) <br /> ;SECTION 4 , ,; r 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 /> rSECTION,S HOME LOCATION <br /> Current Address:3737 PALM HARBOR DRIVE <br /> City:MILLERSBURG County:LINN State:OR Zip:97321 <br /> Park Name: (if applicable) PALM HARBOR HOMES ❑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:4882 LANCASTER DRIVE NE,SP.#2 <br /> City:SALEM County:MARION State:OR Zip:97305 <br /> Park Name: (if applicable) STARLITE MHP ❑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 />