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NATURE OF FILING (checkall.;that applies) <br /> Xpragvativitk0 0 Change ownership ownership NipNaliflog <br /> ClKiteN;Iiesa.efeolvrapecty 0■ Removing from real property status El Trip permit Rtctenur ge <br /> QrsIther: <br /> • APPLICANT;INFORMATION. <br /> ❑ Dealer/seller ❑ Lender ❑ Escrow/title agent Owner/buyer ❑ Legal representative <br /> Name: Roberta O'Dell <br /> . Address(including city, state, and ZIP):PO Box 236, Lyons OR 97358 <br /> Phone: 503-580-8410 or 503-859-3445 <br /> Email: <br /> • HOME.INFORMATION (*required), <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 241794 r •a qs 5 <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: n Coming out of county deed records <br /> n Other: <br /> Manufacturer: Skyline Model: Year: 1983 <br /> Manufacturer serial number HUD number <br /> 01910109S <br /> • <br /> • <br /> *Number of sections: 2 *Square footage: 1568 *Number of bedrooms: 3 *Number of bathrooms: 2 <br /> *Type of roofing: Comp *Type of siding: Metal *Heating: Electric *Cooling:none <br /> *Date of sale:Li *Sales price:$1.00 *Includes land: ❑Yes [11 No <br /> • DEALER INFORMATION if ijo 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 />