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Authentisign ID:5B4F77B9-60C9-EF11 88CF-002248299057 a 410 LanCa S-[eY Dr SE, 1b l a, S cviz✓m 97 3 Y / <br /> SECTION 1 , NATURE OF FILING (check allthat apply) <br /> % New home to MHODS d ' r owner der oPf" i'etf/PBte: ) <br /> ' - :.le 19f\litat'aluglfweatilaperty o ertclAntefage <br /> SrSoeayon s getriteittSJiarfroaniettrprereity status El Trip Permit <br /> rassfeny4SceinteINrfittase-note): <br /> =.,SECTION 2 APPLICANT INFORMATION (please,print) <br /> El 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:MELISA.COOK@CW RES.COM <br /> SECTION 3 °¢,' 'HOME INFORMATION(information in boldFis required) a, <br /> Home ID#:. IV %AiOR No Home ID: ❑■ New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:PALM HARBOR (p 01'5 &(p <br /> Mode1:3104G24523A Year:2025 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> PHH3100R24-16223A ORE 565666 <br /> PHH3100R24-16223E ORE 565667 <br /> #of Sections: .2 Sq.footage: 1196 Bedrooms: 3 Bathrooms: 2 <br /> Roofing type: COMP -= Siding type: LAP CEMENT Heating type: 'ELECTRIC Cooling type: NONE <br /> Date of sale: 1-2-25 Sale price: $136,639 Includes land: ❑Yes D No <br /> of applicable) <br /> ,SECTION 4 _ DEALER INFORMATION (leave blank if no dealer) - <br /> Name: License#: <br /> (first,middle, last) <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 /> SECTIONS HOME,LOCATION - <br /> Current Address:3737 PALM HARBOR DRIVE <br /> City:MILLERSBURG County:LINN State:OR Zip:97321. <br /> Park Name: (if applicable) ❑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:2410 LANCASTER DRIVE SE,SP.#1012 <br /> City:SALEM County:MARION State:OR Zip:97317. <br /> Park Name: (if applicable) SUNDIAL MHC ❑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 />