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•1 �4' <br /> NATURE OF FILING (check all that applies) <br /> se u xt 0 Change ownership Eek i6i e • o ' nr: <br /> —0,d:o d'. _ re:. . • -•". iff\aellkey, ihafeeripjoskpr.optis tg Trip permit te <br /> NJ/644r <br /> _ ` ...:;,4 ;-APPLICANT INFORMATION <br /> ❑ Dealer/seller ❑Lender ❑ Escrow/title agent ❑ Owner/buyer ❑ 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 /> 962867 <br /> ❑ Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ❑ 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: // /2' / q *Sales price: n/a *Includes land: ❑Yes 0 No <br /> DEALER INFORMATION (if no'deale r, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <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 is <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name (print): Dealer signature: Date: <br /> TRANSPORTER INFORMATION (if'not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> 440-2952(7/17/COM) Page 2 <br />