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: , \A Be?- ae, P . #____ <br /> (so n Hu)/ q 9 L- sc.: 2_--7 <br /> 3.--ePr(S0 n <br /> 1325392 <br /> '.... , I .., ::..LNATfli3E.OF 1IIL1NIO,teheck alt that appkes)ry.# :? W <br /> , 4 e tie le it,: _ , - • p <br /> AAA*. s�Lpl y ela '"'''t:, II .a status l l'rip permit U' v age <br /> t r: <br /> a ;:. ;, .}, APPLIOANT`tR9.FO�RMATION <br /> ❑Dealer/seller r}Lender 0 Escrow/title4agent 10 Owner/buyer 0 Legal representative <br /> Name:Rita N Hartzell and Sherri Tredway <br /> Address(including city,state,and ZIP): 14822 JEFFERSON HIGHWAY 99E SW JEFFERSON OR 97352 <br /> Phone: <br /> Email: <br /> :` , !H(IV)E _INFO tW_IATION (*required) <br /> : <br /> Home ID number(if known): DMV X-plate number(if known): <br /> NEW' on \ <br /> 35 <br /> 0 Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> 0 Other: <br /> Manufacturer: CMH HOMES INC Model: Year:2019 <br /> 'Manufacturer serial number £' HUD number <br /> ALB038571ORAB <br /> *Number of sections: 2....., *Square footage:1572. *Number of bedrooms: 3 *Number of bathrooms: <br /> *Type of roofing:q1(h *Type of siding:ueo weditaf *Heating: EjJ(1 *Cooling: <br /> *Date of sale 31 0 Cj *Sales price 14( 'L/ *Includes land: 0 Yes No <br /> __ ,. DEALER INFORMATION(if ilb*4166 leave blank) '_• <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR r-- 1437 CENTURY DRIVE NE <br /> DLR #MSD195 ALBANY OR 97321 <br /> - CCB #166990 (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(prin): Dealer signature: Date: <br /> CktifiErr <br /> F . . <br /> _ ..TRANSPORTER'INFORMATI�. N.(if`not moving, leave blank); ., _ <br /> Transporter name: Transporter�caddress and phone: <br /> t4) i`s-r 146616 'Trots ' LL'2. �'e.--1 e( n o�g.q . 1f5d3)55(- 34 54- <br /> 440-2952(7/17/COM) <br /> OR Title Application-10/2018-TideApp11211 Page 2 004151286-00001 <br />