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. ; <br /> - NATURE OF FILING (check all that applies) <br /> N.A.4.4h~...iateregt. N Change ownership IEN)clogWit W12,a4afklenTUN: <br /> IS/Wg_48 t" aLpr6e?t i ' - o ccrip_rea1kpr6pet-fkgas Trip permit N1,49;fikqpdte <br /> Nr: <br /> APPLICANTANFORMATIOM r-• <br /> El Dealer/seller Lender El Escrow/title agent 0 Owner/buyer D Legal representative <br /> Name:Joetta L Evans <br /> Address (including city, state, and ZIP):PO Box 543, Detroit, OR 97342 <br /> Phone:541-979-5639 <br /> Email: <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 1162867 ; nn I '34,4ci-7 <br /> El Moving in from another state <br /> Has no home ID or X-plate because: El Coming out of county deed records <br /> El Other: <br /> • <br /> Manufacturer:Lamplighter Model: Year:1969 <br /> Manufacturer serial number HUD number <br /> 9209 <br /> *Number of sections:1 *Square footage:528 *Number of bedrooms:2 *Number of bathrooms:1 <br /> *Type of roofing:Metal • .*Type of siding:Vertical Metal *Heating:Electric/pellet St *Cooling:None <br /> *Date of sale: '6/p/.;2,45/ *SaleS price: n/a *Jncludesland: LIYes No <br /> DEALER INFORMATION (if no'clealer,:leave,blank) -v <br /> Dealer name: Dealer license number: Dealer address and phone: <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 is <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name (print): Dealer signature: Date: <br /> • : • <br /> TRANSPORTPRlNFORMATION (uf not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> 440-2952(7/17/COM) Page 2 <br />