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<br /> ❑Change security interest 0 Change ownership ❑Demolition Date of demolition:
<br /> ❑Recording as real property I ❑Removing from real property status 1 ❑Trip permit ❑ Converted to storage
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<br /> ❑Dealer/seller ❑ Lender ❑Escrow/title agent JI Owner/buyer ❑ Legal representative
<br /> Name:Pamela Cooley-Newberry
<br /> Address(including city,state,and ZIP):5037 Cumberland CT SE Salem OR 97306
<br /> Phone:503-371-7468
<br /> Email:
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<br /> Home ID number(if known): •
<br /> DMV X-plate number(if known):
<br /> TBD im '657to ()c
<br /> ❑Moving in from another state
<br /> Has no home ID or X-plate because: ❑Coming out of county deed records
<br /> ['Other:
<br /> Manufacturer: SKYLINE • Model:Halsey Year:2020
<br /> { �'Iii i�uf bture se ih1 iutn>ierH0 number
<br /> 245-000-H-Al 00251A ORE 550308
<br /> 245-000-H-Al 00251 B ORE 550309
<br /> *Number of sections:2 f *Square footage:1354 *Number of bedrooms:2 I *Number of bathrooms:2
<br /> *Type of roofing:ACCH COMP' *Type of siding:ACCH CEMENT 1 *Heating: ELECTRIC *Cooling: NONE
<br /> *Date of sale:9/27/2019 *Sales price:84,086.00 *Includes land:❑Yes ii No
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<br /> Dealer name: Dealer license number: Dealer address and phone:
<br /> Alta Cima DBA PO Box 1295
<br /> Factory Expo Homes MSS 382 McMinnville OR 97128
<br /> 971-267-5024
<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 namerint : Dealer signature: oocuStgned by: t ; c
<br /> (p ) eon.vio /� /2020I 11:5 AM MST
<br /> Factory Expo Homes
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<br /> Transporter name: Transporter address and phone:
<br /> Superior Home Transport 257 N 6th Street
<br /> Jefferson OR 97352
<br /> 503-551-3454
<br /> 440-2952(7/17/COM) Page 2
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