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ie <br /> 11,1 ) 4 Te n2-ns / 0 , l �s <br /> 1308543 <br /> 1 <br /> NATURE OF FILING(check all that applies) <br /> la e s c rit) i r t C 1 e er il, p, • , ►. o . . . 'on: <br /> ((' y ,Tr 1 g rer rt L •, • H.f , . :al ; ,.pe• e rip permit 1 liVeki9tV13 storage <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller Lender —Escrow/title agent <br /> ❑ g _ : Owner/buyer [�Legal representative <br /> Name: Harold Jerry Pietrok and Alyce Faye Pietrok <br /> Address (including city,state,and ZIP): 11712 TEGEN LANE SE AUMSVILLE OR 97325 <br /> Phone: 03- 999-6,,202 <br /> Email: <br /> HOME INFORMATION(*required) _ <br /> Home ID number(if knolvn): r ' 4 DMV X-plate number(if known): �+ <br /> 1 Moving in from another state V O` <br /> i[]Coming out of county deed records Has no home ID or X-plate because: <br /> I 0 Other: <br /> Manufacturer: CMH <br /> Mode]:- Year:2019 <br /> Manufacturer serial number HUD number <br /> ALB038407ORAB <br /> 9 g *Number of bedrooms: 02 <br /> *Number of sections: *Square foota e:�ob0 2 *Number of bathrooms: <br /> *Type of roofing:11,1;, Shi4,11< *Type of siding64,4d 1C<nl 1 *Heating. . *Cooling: k <br /> '�1eCfiYrc -�ut►�t g 1�� )2c,0• <br /> *Date of sale: /k 1 (1 i *Sales price: 9L v5:7198 '98 *Includes land: U Yes �'o <br /> I/ <br /> DEALER INFORMATION(if no dealer,leave blank). <br /> Dealer name: Dealer license n i . • Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR DLR #MSD195 1437 CENTURY DRIVE NE <br /> CCB #166990 ALBANY OR 97321 <br /> (541)967-8555 <br /> n 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: Da e: <br /> v.\„- v\r, \\., - Till rot_ 0,cky-A,a(- <br /> TRANSPORTER4I FORMATaIDN (If not moving, leave blank) <br /> Transporter mune: 'Transporter address and phone: S l 8-i-i3/_53-6 <br /> -01u-L h6L, <br /> 440-2952(7/17/COM) <br /> OR Title Application-10/2018-TitleAppl 121 1 Page 2 004107883.00001 <br />