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{ <br /> 4tsr Assessor's Office <br /> oouci.AS 1036 SE Douglas Ave. <br /> COUNTY Roseburg, OR 97470 <br /> Ph. (541)440-4222/Fax(541)957-2019 <br /> COUNTY CERTIFICATE <br /> Douglas County has received notice of Ownership Document Application for a manufactured home. <br /> NATUREOF FILING r. <br /> 0 Location Change 0 Owner Change <br /> If moving,proposed location: 1� EL, <br /> ►}��-t� t x`13 I <br /> 'APPLICAN.T,INFORMATION ' <br /> O Dealer/Seller 0 Lender 0 Escrow/Title Agent 0 Owner/Buyer 0 Legal Representative <br /> NAME: <br /> ADDRESS: <br /> PHONE: <br /> , _. .n. HOME INFORMATION <br /> HOME ID: VU -AC-4 DMV X-PLATE NUMBER: <br /> 0 MOVING IN FROM ANOTHER STATE 0 OTHER <br /> COMING FROM ANOTHER COUNTY \\._.A ax Nr-1 <br /> MANUFACTUREQA1(n () MODEL: YEAR:-? <br /> NUMBER OF SECTIONS: DATE OF SALE: SALE PRICE: <br /> 'AAIJ*0\7—Signature(Assessor or Representor Printed Name <br /> 4-))' <br /> Title Date <br /> This certification is valid through: 6/2.i./k <br /> Effective September 19,2017 <br />