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• <br /> ,. t <br /> �� ce.nck \)e _ -1- Pc (erv3s38 <br /> 1300214 _ <br /> r — __ i NATURE OF FILING(check all that applie ) __� <br /> — aiage.e cIss14 ' emtzirntaht_1 •ion: <br /> IEi- -ae , status ig Tnp permit. tau-age <br /> _ APPLICANT INFORMATION _ <br /> CIDealer/seller =Q Lender i Q Escrow/title agent $'Owner/buyer (Q Legal representative <br /> !Name:Tim Southerlaud and Lori Southerland <br /> !Address(including city,state,and ZIP) 3 3 _ \.Q.11 ch e. S 1r ret-Lui O^9`)1.37 _—___.. <br /> Phone: <br /> Email: — <br /> __ HOME INFORMATION(*required) <br /> Home ID number(if known): IDMV X-plate number 9knowa); <br /> Q Moving in from another state v — <br /> Has no home ID or X-plate because:I <br /> ❑Coming out of county deed records <br /> I Q Other: <br /> Manufacturer:CMH — (Model: a 1,1 O - ( -- Year:2018 <br /> — _ —..__ <br /> Manufacturer serial number ' D number <br /> ALB038138ORAB <br /> Number of sections: � � S uare footage: j(}p _-- _ � — --_T _ _____ -___— <br /> i* ,* 9 g 2 �*Number of bedrooms: *Number of bathrooms: Z. <br /> i i <br /> *Type of roofing: sill n Ai e *Type of siding:c.i>!l ,l 11 is 1 1*Heating: e jut*i % ;*Cooling: ,-- -- <br /> *Date of sale: /1- 111 i S; f *Sales prices IN,551f*includes land:h Yes -No _—— -1 <br /> _ <br /> DEALER INFORMATION (if no dealer,leave dank) <br /> Dealer name: Dealer license number: eater address and phone: <br /> CLAYTON HOMES ALBANY,OR ` DLR #MSD195 1137 CENTURY DRIVE NE <br /> -; CCB #166990 trILBANY OR 97321 <br /> I____ _ ___s___— �. ( 41)967-8555 <br /> E 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 nd belief,and that I understand it <br /> I is made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print): — v _ T Dealer signature: Date: <br /> 1 <br /> ._�1_,%4_1":, 1on c to __ _L.ak t Icc.A�__ ___ (. Lt&' J <br /> i TRANSP Ot TER INFORMATION(if not moving, Wave blank) <br /> !Transporter name: — Transporter address and phone: S'18-G 3 Lf-5c1 <br /> (- f3\U.Q. -4 0. <br /> _ u`. __. -.__-. _310291 •i-1 t n 2-20S t a aft Ci-I 3 7 -- <br /> Li _. <br /> 440-2952(7/17/COM) <br /> OR Title Application-12/2017-TitleAppl 1211 Page 2 004085888.00002 <br />