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�o r <br /> 1317298 <br /> NATURE OF FILING.(check all that applies) <br /> ii t.h + _ .t_._•t i D <br /> o n: <br /> Ki/"det� (,t J'I'rip permit C v e ora <br /> le <br /> } <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller ❑Lender ❑Escrow/title agenty�wner/buyer ❑Legal representative <br /> Name:Jeff Decosta <br /> Address (including city,state,and ZIP):23651 MEADOW DR NE AURORA OR 97002 <br /> Phone: <br /> Email: <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): 1DMV X-plate number(if known): <br /> NEW -35~7 ao5 <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: CMA 'Model: Year:2019 <br /> Manufacturer serial number I HUD number <br /> ALB038418ORAB <br /> *Number of sections: 2 l*Square footage: I ys/J*Number of bedrooms: '. l*Number of bathrooms: 2.... <br /> *Type of roofing:9h;,)k 2 *Type of siding: eatn <br /> SMaf4.vU.rtE..� *Heating: 0 Q L.1`,6('_ iCooling: k) <br /> *Date of sale: 1 q II\of *Sales price: " *Includes land: 0 Ye -No <br /> DEALER INFORMATION (if no dealer, leave blank); -. <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR {\I S . 1 Ctr—, 1437 CENTURY DRIVE NE <br /> ALBANY OR 97321 <br /> (541)967-8555 <br /> 0 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 /> 0, 6 Atkirl 1 ----\t>s Air i ' ,t- i _ _ ,- _r .`f( (E.''' i r C' <br /> TRANSPORTED'"INFORMATI 0 N(if not moving, leave blank) <br /> Transporter name: Transporter address and phone: g'I 131451-1- 0 1 <br /> ! _. 32 7C1 I-41MM 224 S Gi o 0 R. '137 LI <br /> 440-2952(7/17/COM) <br /> OR Title Application-10/2018-TitleApp11211 Page 2 004128728-00002 <br />