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c q ce:r• -Y-al s•L,Gcs <br /> • •• • NATURE OF,FILING (check alt that applies) <br /> f•7 �' :• :• >t = -' t Q Change ownership ■:a,.n • iti. = o • •• on: <br /> r1 ee: ; ;i _ 4. . )r• e1 . 'n!, •o e- '••rt'e,latus ❑■ Trip permit "b e eI sto• e <br /> 5fi lIr: <br /> ' APPLICANT-INFORMATION' <br /> 0 Dealer/seller ❑ Lender ❑ Escrow/title agent ❑ Owner/buyer • ❑ Legal representative <br /> Name:HOMES DIRECT OF OREGON <br /> Address(including city,state,and ZIP):3838 PALM HARBOR DR NE, MILLERSBURG,OR 97321 <br /> Phone:541-928-2083 <br /> Email:neilaw31@gmail.com <br /> HOME INFORMATION (* required) . <br /> I-{ome ID number(if known): DMV X-plate number(if known): <br /> NEW 35-1-7U) <br /> ❑ Moving in from another state <br /> Has no home ID or X-plate because: H Coming out of county deed records <br /> ❑Other: <br /> Manufacturer:PALM HARBOR Model:310AF15762R Year:2020 <br /> Manufacturer serial number HUD number <br /> PHH3100R19-13428A ORE547387 <br /> *Number of sections:1 *Square footage: 1140 *Number of bedrooms:I *Number of bathrooms:3 <br /> *Type of roofing:.COMP. *Type of siding:VERT.CEMENT *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:06/28/2019' *Sales price:$88,046.00 *includes land: ❑ Yes ❑■ No <br /> DEALER.INFORMATION (if,no dealer,'leaVe blank)' <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> HOMES DIRECT OF OREGON MSD523 3838 PALM HARBOR DR NE <br /> MILLERSBURG, OR 97321 <br /> (541)928-2083 <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 structre. <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 /> NEILA WHITE I) 2 9/3/2019 <br /> • ,TRANSPORTER INFORMATIO (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> BENNETT TRUCK TRANSPORT . PO BOX 503098 <br /> WHITE CITY, OR 97503 (541)879-3444 <br /> 440-2952(7/17/COM) Page 2 <br />