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• - ' '- NATURE OF.FILING (check all that applies) <br /> ❑Change security interest _0 Change ownership 0 DemoIition Date of demolition: <br /> ❑Recording as real property IV Removing from real property status ID Trip permit 0 Converted to storage <br /> 0 Other: . <br /> . - • --.;;APPLICANT INFORMATION . . - ' . - - <br /> r ElDealer/seller T 0 Lender 0 Escrow/title agent i 0 Owner/buyer ay ❑Legal representative <br /> Name:Dougs Mobile Home Service INC <br /> Address(including city,state,and ZIP):12692 Fry rd Aurora or 97002 • <br /> Phone:503-799-0539 <br /> Email:dugwaiton@aol.com <br /> -.. • :- :: . . . .. .• . HOME INFORMATION - --- -- '- --� . <br /> r <br /> Home ID number(if/o:own): DMV X-plate number(if known): <br /> - ❑Moving in from another state <br /> Has no home ID or X-plate because: [Coming out of county deed records <br /> 0 Other: <br /> Manufacturer: (� <br /> ��esi"L�- iX Model: Year:l q q 3 <br /> Manufacturer-serial number HUD number <br /> okRy Li - 8'A-36ILIic67--c,P <br /> *Number of sections: 3 *Square footage: i 77 *Number of bedrooms: 3 *Number of bathrooms: 'Z <br /> *Type of roofing: C *Type of siding:-r1 ...../ / *Heating: f *Cooling: .e-- <br /> ' <br /> *Date of sale: his 1(1, r *Sales <br /> price: 114i i 000 *Includes land:0 Ycs ,®No <br /> DEALER INFORMATION (If no dealer, leave blank) . <br /> Dealer name: Dealer license number Dealer address and phone: <br /> Dougs Mobile Home Service INC 652 12692 Fry rd Aurora or 97002 <br /> 503-799-0539 <br /> cji 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 si Date: <br /> Doug Walton <br /> ;TRANSP.ORTER INFORMATION (Ifno -moving, leave-blank)' <br /> • , -.- •'. .. . : .. <br /> Transporter name: <br /> Transporter address and phone: <br /> Dougs Mobile Home Service INC 12692 Fry rd Aurora or 97002 . <br /> r <br /> b 4 1 AO Ail !� 11 idtt 6 2111 I . i . i <br /> 440-2952(7/17/COM) Page 2 <br />