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NATURE OF FILING(check all that applies) <br /> ❑change security-interest, e-ewnershitt- ©-Dernolttion—Ham #- oli <br /> [}Recording-as-real-prepejty ®-Itettro ving-fronrreal-propertystatus �®Trip permit -onverted-to-storage <br /> 9ther r' <br /> APPLICANT INFORMATION . <br /> ❑Dealer/seller ❑Lender 0 Escrow/title agent 0 Owner/buyer ❑Legal representative <br /> Name:Fidelity National Title Company of Oregon <br /> Address(including city,state,and ZIP):500 Liberty St SE,Ste 200,Salem OR 97301 <br /> Phone:503-585-7219 <br /> Email:deone.wilson@fnf.com <br /> HOME INFORMATION (*.required) <br /> Home ID number(i[known): DMV X-plate number(if known): <br /> 292864 X00248128 37,P-115 <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> ❑Other: <br /> Manufacturer:Guerdon Model:Unknown Year:1998 <br /> Manufacturer serial number HUD number <br /> GDSTOR259820176 <br /> *Number of sections: *Square footage:1188 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Composition *Type of siding:T1-11 Hardwood *Heating:Heat Pump *Cooling:Heat Pump <br /> *Date of sale:11/15/17 *Sales price:$35,000.00 *Includes land:❑Yes El No <br /> DEALER INFORMATION (if no dealer, leave blank). <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> Q 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. <br /> I hereby declare that the above statement is true to the best of my knowledge and belief,and that I understand it is <br /> made for use as evidence in court and is subject to penalty for perjury. _ <br /> Dealer name(print): Dealer signature: Date: <br /> TRANSPORTER INFORMATION (if not moving, leave blank) " • <br /> Transporter name: Transporter address and phone: 563- ,.)37.-- <br /> �` Loo P 50-3-•'6511 -975 <br /> Qorni„v15 Mob% 77-405 405 c+r i t c) tx /? <br /> 440-2952(7/17/COM) Page 2 <br />