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t tdl -th <br /> qd-.7 , <br /> 1360135 <br /> NATURE OF FILING(check all that applies) . <br /> fl Change security interest 0 Change ownership [1 Demolition Date of demolition: <br /> Recording as real property Removing from real property status <br /> rip permit 0 Converted to storage <br /> Other: <br /> APPLICANT INFORM.a.=ION <br /> [�Dealer/seller fl Lender [J Escrow/title agent § Owner/buyer Y Legal representative <br /> Name:Mildred Brinlee <br /> Address(including city,state,and ZIP):7927 4TH ST.TURNER TURNER OR 97392 <br /> Phone: <br /> Email: <br /> HOME INFORMATION(*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: 0 Coming out of county deed records <br /> (]Other: <br /> Manufacturer: CMH Model: 72TRL28603AH17 <br /> Manufacturer serial number Year:2017 <br /> HUD number <br /> ALB036755ORAB O R, ,. SS67 <br /> *Number of sections: 2 *Square footage:WO b *Number of bedrooms: <br /> 3 *Number of bathrooms: � <br /> *Type of roofmg:\2h SHthc lis siding:slur/of sidi �r <br /> M / ( Heating: •iq.S -�,rr,� *Coaling: <br /> *Date of sale: a .0 *Sales price: <br /> IO 1020 *Includes and: D Yes <br /> DEALER INFORMATION (if nci dealer, leave blank) <br /> Dealer name: Dealer license number: <br /> CLAYTON HOMES ALBANY, OR _ Dealer address and phone: <br /> DLP, #fA45D195 1437 CENTURY DRIVE NE <br /> CCB t/166990 ALBANY OR 97322 <br /> (541)967-8555 <br /> IF This manufactured structure is free and clear of all mortgages, deeds of trust,security interests,and liens.I have the <br /> 1--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 /> is made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print) <br /> Dealer signature: Date: <br /> Ji�,tar • s til w2 L t <br /> TRANSPORTER INFORMAT.; N(if not moving, leave blank) <br /> Transporter name: Transp. er address and phone: <br /> 8t8• t.m.S a. <br /> sa\ rac o ) • <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TitleApp11211 <br /> Page 2 <br /> 004233606-00001 <br />