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. <br /> NATURE OF FILING (check all that applies) <br /> ❑ Cl, *+ ,&ccatu:4.'iaa,1 st ❑ -lagetuektien Daition: <br /> • <br /> ❑ Reeo► in -ac= rty ❑Remo.;..a P eal �t tus Trip permit [ -GetwerteekeTstc a e <br /> Othrpr <br /> ❑ : <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑Legal representative <br /> Name:CASCADE FACTORY HOMES, INC <br /> Address (including city,state,and ZIP):590 N. PACIFIC HWY,WOODBURN,OR 97071 <br /> Phone:(503)981-5314 <br /> Email:CASCADEHOMES@YAHOO.COM <br /> . .HOME INFORMATION (* required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> N v.) ir‘f, 3556/615 lV r L1/4) <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: .❑Coming out of county deed records <br /> ❑Other:New home <br /> • <br /> . Manufacturer:PALM HARBOR HOMES Model:4G28362A Year:20119 <br /> Manufacturer serial number HUD number 1 <br /> PHH3100R18-12894A ORE 542033 <br /> PHH3100R18-128946 ORE 542034 <br /> *Number of sections:2 *Square footage:972 *Number of bedrooms:2 *Number of bathrooms:1 <br /> *Type of roofing:COMPOSITIO *Type of siding:CEMENT *Heating:ELECTRIC *Cooling:NO • <br /> *Date of sale: *Sales price:56,599.00 *Includes land: ❑ Yes El No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: • <br /> CASCADE FACTORY HOMES, INC MSD-41 590 N. PACIFIC HWY <br /> WOODBURN,OR 97071 <br /> (503)981-5314 <br /> ElThis 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 <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> • <br /> Dealer name (print): Dealer signature: Date: <br /> CASCADE FACTORY HOMES, INC <br /> TRANSPORTER INFORMATION (If not moving, leave blank) <br /> Transporter name: Transporter address and phone: • <br /> p Po <br /> SUPERIOR HOME TRANSPORT 257 N. 6TH <br /> JEFFERSON, OR 97352 <br /> 541-327-7805 <br /> • <br /> 440.2952(7/17/COM) Page 2 <br />