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700 CRci 5'. . i <br /> 1359902 <br /> NATURE OF FILING(check all that applies) i <br /> orj i ,g ,• • f A:, i r . ,!.- , i.'4 9 , ' / h5)Wikelfedkratikrafri. <br /> J i i* g r r Trip permit ! "14Afkge <br /> I Lam: <br /> APPLICANT INFORM TION <br /> Q Dealer/seller C Lender 0 Escrow/title agent Owner/buyer Q Legal representative <br /> Name:Joseph Johnson and Jenniffer nichol Helms Johnson <br /> Address(including city,state,and ZIP): 700 CORDON RD SE SALEM OR 97317 <br /> Phone: 543—Sv 3_777 <br /> Email: <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): JDMV X-plate number(if known <br /> Moving in from another state <br /> Has no home ID or X-plate because:l Coming out of county deed records <br /> Q Other: <br /> li <br /> Manufacturer:CLAYTON Model: 72QLV42664AH19 Year:2019 <br /> Manufacturer serial number HUD number <br /> ALB039252ORABC T <br /> *Number of sections. S *Square footage:.2 ,ypj*Number of bedrooms: y I*Number of bathrooms: L." <br /> *Type of roofing:4 A sky, *Type of siding:5paci. 4./ Heating: Cooling: <br /> *Date of sale: i *Sales prici 1`13 10 I*Includes land: :Yes No <br /> DEALER INFORMATION (if no dealer, leave blank)( <br /> Dealer name: Dealer l1 �mxtk}'t�1 g5 w Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR 1437 CENTURY DRIVE NE <br /> (LD 1 166990 ALBANY OR 97321 <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 /> I is made for use as evidence in court and is subject to penalty for perjury. <br /> I Dealer name(print): ealer signature: Date: <br /> 1 <br /> 1 1k,‘\IC A ` ,\,t-t\r\v,.:-.) \\\\}\\ •\-\_\,\,t.,,,k&f....,( k t/- <br /> TRANSPORTER INFORMATION(if not moving, leave blank) <br /> Transporter name: <br /> 1Transporter <br /> address and phone: 5 f 6_y3 t f.5541 <br /> 1 <br /> L iU -� }ctu� <br /> i317;�0iIiWv 22( Cin 6g g787 <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TitleApp11211 Page 2 004239555-00001 <br />