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NATURE OF FILING check;all that-applies) <br /> 01 .3S 99(01- <br /> iv,Q2ygre—ce'nrity interest 111 Change ownership e of demolition: <br /> ❑ Rec. ding .: e e :: a . ;.. _-al property status El Trip permit ❑Converted to storage <br /> ❑ Other: <br /> APPLICANT INFORMATION <br /> ❑� Dealer/seller ❑Lender ❑ Escrow/title agent ❑ Owner/buyer y ❑ Legal representative <br /> Name:LEISURELAND HOMES INC <br /> Address(including city,state,and ZIP):33964 OAKVILLE RD SW ALBANY OR 97321 <br /> Phone:5419281555 <br /> Email:LEISURELANDHOMES@GMAIL.COM <br /> HOME INFORMATION (*required); <br /> Home ID number(iifknnown): DMV X-plate number(if known): <br /> I\DV <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> El Other:NEW HOME <br /> Manufacturer:FLEETWOOD-WINGATE Model:28603G Year:2020 <br /> Manufacturer serial number HUD number <br /> FLE2100R19-19926A+B ORE547453 <br /> ORE547454 <br /> *Number of sections:2 *Square footage:1599 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:ARCH *Type of siding:CEMENT *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:06-04-2019 *Sales price:9(11 <br /> *Includes land: ['Yes 0 No <br /> DEALER INFORMATION,if no dealer,,leave,blank <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> LEISURELAND HOMES INC MSD119 33964 OAKVILLE3 RD SW <br /> ALBANY OR 97321 <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): !-• -. • =1'a _ Date: <br /> LEISURELAND HOMES INC �. � tC �I 8/19/2019 <br /> TRANSPORTER INFORMB►TION (if not moving,Eleave blank) <br /> Transporter name: Transporter address and phone: <br /> SAME AS ABOVE SAME AS ABOVE <br /> 440-2952(7/19/COM) Page 2 <br />