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9 7 -7 -1--ctLy-1--on R SE, A tor s u ; <br /> 1353699 <br /> +iATURE OF FILING(check all that appties); <br /> If � ' s C 'ty ''tey,.t � _ �j(�:� i „ . o 1.n 'ate . 'd- . Iti,• <br /> • <br /> � <br /> y� ., �. 'q, ♦' ' • I •.1 , ..;Tr }� Li Trip permit it ��f e <br /> I' r: <br /> APPLICANT INFORMATION <br /> Dealer/seller []Lender 0 Escrow/title agent IL Owner/buyer []Legal representative <br /> Name:Karen Hagel <br /> Address(including city,state,and ZIP): 9777 STAYTON RD SE AUMSVILLE OR 97325 <br /> Phone: <br /> Email: <br /> HOME INFORMATION (*required) <br /> Home ID �num11 r,(if known): DMV X-plate number(if known):W m 35 83 O a- <br /> 0 Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> Other: <br /> Manufacturer: CLAYTON Model: Year:2019 <br /> Manufacturer serial number HUD number <br /> ALB039121ORAB <br /> *Number of sections: Z. *Square footage:Zcfry *Number of bedrooms: 3 *Number of bathrooms: -- <br /> *Type of roofing: C. *Type of siding: *Heating: > *Cooling: HP <br /> *Date of sale: I 0/9//7 *Sales price:isC(3 - *Includes land: El Yes No <br /> DEALER INFORMATION(if no dealer, leave blank) <br /> Dealer name: Dealer license number: (Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR 114437 CCEYTOR Y DRIVE NE <br /> Yhs� I'S� <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 s exralcy fo erjury. <br /> Dealer name(print): D:0- er signal a Date: <br /> ►v-ce. —..-4044111 (D/9/i , <br /> TRANSPORTER INFORMATION(if moving, lea a blank) <br /> Transporter name: I Transporter address and phone: ' ,l <br /> .5q-z-42=14 y Z'L(o Sc-i o ,o t - 9 3-4 <br /> -1)(v e_ lc11 5'-`13``i' S'SO I <br /> 440-2952(7/17/COM) <br /> OR Title Application-10/2018-TitleApp11211 Page 2 004222708.00001 <br />