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. it0ry.. 3 09 1 Rc4.;nbow Lop *.3 46 x8306 So no) lake RA C)ooevelcc. <br /> NATURE OF FLING (check all that applies) <br /> ❑Change security interest 1 Change ownership ❑Demolition Date of demolition: <br /> 0 Recording as real property ❑Removing from real property status (Trip permit ❑Converted to storage <br /> ❑Other: <br /> APPLICANT INFORMATION <br /> ❑Dealer/sell�er-�; ❑Lender ❑Escrow/title agent 1Owner/buyer ❑Legal representative <br /> Name: K 1`/� lr 'I44-610N— l-n A S6 o <br /> Address(including city,state,and ZIP): I'J..--116 SV v `Zj30)4-1g POeinAND Ti 2/2 <br /> Phone: 0 7 ,S 1(Q .(els+ <br /> Email: <br /> HOME INFORMATION (*required) <br /> Home ID numb r(f known): DMV X-plate number(if known): <br /> Wv �6IAI D !w) ,I' 1/300 ;nn 1 '.'2-7-?, <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: Model: Year:i p(,y. <br /> manufacturer serial number BUD number <br /> j J i o iii//� <br /> *Number of sections:/ *Square footage:09 *Number of bedrooms: A *Number of bathrooms: / <br /> *Type of roofing: i,-I-p *Type of siding: *Heating: gja4-7,« *Cooling: N/(4-• <br /> *Date of sale: //,'4 o/ `, *Sales price: *Includes land:0 Yes [2'&o <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 /> 440-2952(7/19/COM) Page 2 <br />