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SECTION 1 - NATURE OF FILING(check all that apply) <br /> ❑ "New home to MI-IODS _ INIA Adding or removing a co-owner ❑ Demolition(Date: ) <br /> ❑ Used home sale ❑ Recording as real property ❑ Converted to storage <br /> U. ,Security interest change ❑ Removing from real property status ❑ Trip Permit <br /> ❑ Transfer by inheritance ❑ Other(please note): <br /> SECTION 2 - . APPLICANT..INFORMATION (please print) _ <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent 'Owner/Buyer ❑Legal Representative <br /> Name: mrn ,f � l I ' <br /> (first;middle,-last) 0, CVO-)W Phone ci-C ` f / <br /> 27/ <br /> Address: 12 1 Q f i . <br /> City' al State: 0 ZIP: �J�. <br /> �EmaiL• <br /> pkcvlo q7 �.Z@, YYl4,i I I . c 'Y <br /> SECTION 3 HOME INFORMATION'Onformation in bold is required) ROCA- `Gt- I tiOi L4-33- <br /> Home ID#: 23 2 O Lf V OR No Home ID: 0 New Home ❑Out of state home D Leaving County Deed Records <br /> Manufacturer: 1 dQArm1MV _4-a a <br /> Model: - 5O Y)'1PJt'S Year: i q r�� <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> #of Sections: Sq.footage: c(50 Bedrooms: 3 Bathrooms: ?j .,Roofing type: _ 1 OM Ops , Siding type:" � 1`lr- Heating type: : t.eJ,_,-�, Cooling Type g <br /> Date of sale:afapplicable) 0 ?-1„a5Sale price: O O Includes land:; ❑Yes No • <br /> SECTION 4 ,- _ �' �. <br /> DEALER INFORMATION (leave blank ifno dealer) <br /> Name: • . <br /> License#: <br /> first,middle,last) <br /> Address: <br /> City: State: ZIP: <br /> Email: Phone: <br /> 1 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 ldtowledge 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: I Z71 {i3t _A e. 1V1' <br /> City: _ WCounty: T lain all State: ( Zip:(' <br /> Park Name:(if applicable) r ., .S ❑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: <br /> City: County: State: Zip: <br /> Park Name:(if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name: i Phone: <br /> Address: City: I State: <br /> Email: <br /> Page 2 <br />