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B -7 D PteasarLOJ7M'cv- <br /> 1335313 <br /> NATURE OF FILING(check all that applies) <br /> WSczeis e • t r ... dq al✓ aro ' n: <br /> t ' IVY <br /> op-. Trip permito t bra e <br /> g <br /> nOter <br /> APPLICANT INFORMATION <br /> Dealer/seller 0 Lender . 0 Escrow/title agent 0 Owner/buyer U Legal representative <br /> Name:Ricardo Chavez alvarez and Helena May Chavez <br /> Address(including city,state,and ZIP):8276 PLEASANT GROVE RD SE TURNER OR 97392 <br /> Phone: <br /> Email: <br /> HOME INFORMATION(*,required) ,. <br /> Home ID number(if known): DMV X-plate number(if knownM <br /> 0 Moving in from another state <br /> Has no home ID or X-plate because: <br /> Fl Coming out of county deed records <br /> 0 Other: <br /> Manufacturer:CMH Model: Year:2017 <br /> Manufacturer serial number I HUD number <br /> ALB036792ORAB <br /> *Number of sections: 2. l*Square footage: Is-12 *Number of bedrooms: *Number of bathrooms: Z <br /> *Type of roofing: ( ff^? *Type of siding: ?Ah Q,‘ *Heating: f{E *Cooling: <br /> *Date of sale: ((Z - *Sales price: g Gt 7o1-lO 0 *Includes land: Li Yes ^( No <br /> DEALER INFORMATION-(if no dealer,leave blank) <br /> Dealer name: Dealer'Iicer ue n nher' ,, 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 /> ®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: Date: <br /> - r 71.2-9 1R <br /> � Q <br /> TRANSPORTER INFORMATI N(if not movinleave blank) <br /> Transporter name: Transporter address and phone: <br /> 13t�� u.L)� - zo'l Nwy 2i 6 Sc.tct c Z °t'7 3.7c4 <br /> i13q-.51'6/ <br /> 440-2952(7/17/COM) <br /> OR Title Application-10/2018-TitleApp11211 Page 2 004175519-00001 <br />