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b 1 <br /> cn <br /> Authentislgn ID:5B4F77B9-60C9-EF11-88CF-002248299057 a 4 Y O L a s-lry Dr SE, l v W iVw) / <br /> SECTION 1 NATURE OF FILING (check all that apply) • <br /> ❑� New home to MHODS d ' r -owner '9"VerShcrtietf/Pate: ) <br /> - :.le 5 o�Lr tlirdforellebperty o ei r-age <br /> ti n ge status ■❑ Trip Permit <br /> ESL.TaufenfrigherigkceerTILase-note): <br /> :SECTION 2 ,',;,, APPLICANT INFORMATION (please print) „; <br /> ❑� Dealer/Seller ❑Lender D Escrow/Title Agent El Owner/Buyer ❑Legal Representative <br /> Name:COMMONWEALTH HOMEOWNER SERVICES Phone:503-244-2300 <br /> Urst,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#:. Iv E 1/1/4,) OR No Home ID: ❑■ New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:PALM HARBOR � ]' (>i(p <br /> Mode1:3104G24523A Year:2025 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> PHH3100R24-16223A ORE 565666 <br /> PHH3100R24-16223B 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 E No <br /> (If applicable) <br /> SECTION 4 DEALERINFORMATION(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:3737 PALM HARBOR DRIVE <br /> City:MILLERSBURG County:LINN State:OR Zip:97321. <br /> applicable) This is a dealer lot or storage facilit <br /> y <br /> Name: (if ❑ g <br /> ❑■ 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 El 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 />