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41 (8 8 DarI C as k) B 3 NATURE OF FILING (check all that applies) ❑ Change security interest ❑ Change ownership ❑ Demolition Date of demolition: ❑ Recording as real property ❑Removing from real property status 1c Trip permit ❑ Converted to storage ❑ Other: APPLICANT INFORMATION ❑ Dealer/seller ❑ Lender ❑ Escrow/title agent 0 Owner/buyer ❑ Legal representative Name:Theodore Viandi Address (including city, state, and ZIP):4882 Lancaster Dr NE Unit 83, Salem OR 97305 Phone:417-259-9298 Email:tedviandi@gmail.com HOME INFORMATION (*required). • Home ID number(if known): DMV X-plate number(if known): 31843c ci5-7 n Moving in from another state Has no home ID or X-plate because: ❑ Coming out of county deed records n Other: Manufacturer:Fleetwood Model:Broad more 2602L Year:2007 Manufacturer serial number HUD number SN 31841 ORE499391 oPSL-7 48 ►� 31t��1� Brn13 *Number of sections:1 *Square footage:800 *Number of bedrooms:2 *Number of bathrooms:1 *Type of roofing:Shingle.: *Type of siding:Hardi *Heating:heat pump *Cooling:Heat pump *Date of sale:2/28/2020 *Sales price:$10,000.00 *Includes land: ❑ Yes 0 No DEALER INFORMATION (if no dealer, leave blank) " Dealer name: Dealer license number: Dealer address and phone: ['This manufactured structure is free and clear of all mortgages, deeds of trust, security interests, and liens. I have the legal right to sell this manufactured structure. I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Dealer name (print): Dealer signature: Date: TRANSPORTER INFORMATION (if not rrioving,.leave blank) Transporter name: Transporter address and phone: JC Crawler Service 492 Kay Lynn Way NE, Salem OR 97301503-510-9580 440-2952(7/19/COM) Page 2