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NATURE OF FILING (check all that applies) <br /> ❑ Change security interest 0 Change ownership ❑ Demolition Date of demolition: <br /> ❑Recording as real property ❑Removing from real property status 0 Trip permit ❑ Converted to storage <br /> 0 Other: Moving mobile home from Park to a new location (245 N Santiam Hwy E.,#19, Gates, OR 97346 <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller ❑ Lender ❑ Escrow/title agent 0 Owner/buyer ❑ Legal representative <br /> Name: PATRICIA CUNNINGHAM; JOHN PINARD <br /> Address(including city, state, and ZIP): 245 N SANTIAM HWY E., #19, GATES, OR 97346 <br /> Phone:(503) 551-1165 <br /> Email:O REGONLADY54@G MAI L.CO M <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 198626 y'\1.7 <br /> - , - 1 X00125349 <br /> [' Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> n Other: <br /> Manufacturer: SKYLINE Model:HILLCREST Year: 1975 <br /> Manufacturer serial number HUD number <br /> 02950403J <br /> *Number of sections: 1 *Square footage: 924 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:COMP *Type of siding:METAL-LAP *Heating:ELECTRIC *Cooling:NONE <br /> *Date of sale:1/21/2020 *Sales price: 2,700.00 *Includes land: ❑ Yes ■❑No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <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): Dealer signature: Date: <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> MARTIN DUNN, SITE INSPECTION SERVICE, LLC 2390 ALAMEDA STREET NE., SALEM, OR 97301 <br /> (503) 991-1808 <br /> 440-2952(7/19/COM) Page 2 <br />