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- • . <br /> NATURE OF FILING (check all that applies) <br /> ❑Chan_ -iRt'rest ® Change ownership ❑•P- • • i:= • •-. • ition: <br /> ❑ or ng as re1-property ■ ' :: t -,• • i - -. tg Trip permit otiverted forage <br /> nether: <br /> APPLICANT INFORMATION <br /> xi Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑Legal representative <br /> Name: Re Pht b 97uJ1 t <br /> Address(including city,state,and ZIP): L4C d e,D, k..oti.sa,Qvktte t 9ici7 <br /> Phone: 5O --73A-3(4,60‘ <br /> Email: cSerudf tC6S.Nvlt-g64.nAll--•cal", <br /> HOME INFORMATION (*`required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 36.5e4ca xba®®i°t'-t1co rniD.4 533 <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: Model: XIE.gWd®+) Year: c--1 <br /> Manufacturer serial number HUD number <br /> f4 <br /> *Number of sections: *Square footage:%t4(24 *Number of bedrooms: 3 *Number of bathrooms: <br /> *Type of roofing:M •m_. *Type of siding: p,1. . *Heating:C T1 *Cooling:escctti <br /> *Date of sale: A *Sales price: * © *Includes land: ❑Yes ►1 No <br /> • <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> ❑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: • <br /> P--1 OTT KOtalLE t4.6We Ser—UP t?®., I0 Lk Co Sett —°t3SD-Caq� <br /> P. 91491 <br /> 440-2952(7/17/COM) Page 2 <br />