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. 19-q6) nq ci5)- Lh �� <br /> 1293463 <br /> • NATURE OF FILING (checkall tlat'applies) <br /> st ❑ hip l=Berrrclitien n: <br /> rty ❑ tus C[2trip permit Cony +^stnrage <br /> ❑(mer: <br /> APPLICANTINFORMATION ' ... <br /> Dealer/seller ❑Lender ❑Escrow/title agent `3iOwner/buyer ❑Legal representative <br /> , <br /> Name:Wesley Jensen and Kathleen Jensen w1 A'XLt'1.l <br /> Address(including city,state,and ZIP): \3-i C.e4.01-vvi �� ;J lel r Ota 9"I 3 jI <br /> Phone: ��i q6-7_ <br /> 8 <br /> Email: <br /> S-I C 61 3 (i.:'a QA,A.lir ri k yM <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): F`� ) DMV X-plate number(if known): M 35(0O(s2 C) <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:CMH Model: ()L 7 0 c!14 - Year:2018 <br /> Manufacturer serial number HUD number <br /> ABLO38058ORABCAC <br /> *Number of sections: ', *Square footage: t 8p *Number of bedrooms: Li *Number of bathrooms: 3 <br /> *Type of roofing:41 ; *Type of siding: P.9ri4 *Heating: C al1. *Cooling: <br /> *Date of sale: -7/, 5)J8 *Sales price: 202.2 Lts- *Includes land: jYes ❑No <br /> DEALER INFORMATION(if no dealer,leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR 1 DLR #MSD195 1437 CENTURY DRIVE NE <br /> CCB #16699Q ALBANY OR 97321 <br /> (541)967-8555 <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 <br /> is made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print): Dealer signature: Date: <br /> u 4 l1725.11c, � j tlt e v�tc t(.i r?-L,F:;j ) if 1 (—•\ CI.;'.� ._.�.:t C <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Trans otter Iddress an phone: <br /> _scu) c co-s-pi 12 -LI 5 - .c30( <br /> 440-2952(7/17/COM) <br /> OR Title Application-1212017-TitleApp11211 Page 2 004073768-00002 <br />