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NATURE OF FILING (check all that applies). <br /> NiaShays.geatilibikinoat KLaaRPssmunliiig BDfdifln ‘1/49." Ae-CAND.tilmt: <br /> 1 rty e s XI Trip permit vert d storage <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller ❑Lender ❑Escrow/title agent If Owner/buyer ❑ Legal representative <br /> Name: Re No <br /> Address(including city,state, and ZIP): IliCao acsus`~�� p (s, UAL,St pkv,u a 8e, 1 CCt, <br /> Phone:503—`P c1-3 Cr,,50( <br /> Email: A,C.%t,vtic6s. <br /> HOME INFORMATION (* required). <br /> Home ID number(if known): DMV X-plate number(if known): <br /> aCa,V8ti ir-Y\'eb b5j <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: x-i\ t 3®a_)A6, Model:ii,,.y.A‘s(273 c Year: aS <br /> Manufacturer serial number HUD number <br /> *Number of sections: `1 *Square footage:`L,J 0 *Number of bedrooms: 2, *Number of bathrooms: <br /> *Type of roofing: Cal n,c *Type of siding: Rim G *Heating:'b.1 p-c a u p *cooling: -l6 c.pump <br /> *Date of sale: 01A *Sales price: tal *Includes land: ❑Yes j1 No <br /> DEALER INFORMATION (if no dealer, 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 />