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qB721G0I 'CTbt3 <br /> NATURE OF FILING(check all that applies) <br /> C[ s to t 71 Change ownership ❑ o <br /> R." - ae l ertyov' .f real it ve ge <br /> ]'Other. <br /> APPLICANT INFORMATION <br /> ,Deale <br /> r/seller 0 Lender ❑Escrow/title agent 0 Owner/buyer 0 Legal representative <br /> Name: /7// PVT M&ntkPosikl i AD-me-5 <br /> Address(including city,state,and ZIP): /640 Mtv'?ey r$1'. $E� ��r�Cr soali DE '17352. <br /> Phone: $'NF1-Go(Pfo- bcib‘ 1 <br /> Email: Gil Weir My10 W1 G1d l•CAM <br /> I YOME INFORMATION(`required) • <br /> Home ID number(ifbrown): <br /> Ni E AI DMV X-plate number(if known): <br /> Co 6 D-I 8 <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:/lDrikwlcst Fln'rVIC 31M1AleYS Model:G 00 q 55 Year:/151 <br /> Manufacturer serial number HUD number <br /> 2,1391P 00 I55 age"- 3/4,2 9.2_ <br /> *Number of sections: ,2 *Square footage:/G 2D *Number of bedrooms: f *Number of bathrooms: 2 <br /> *Type of roofing: (MQ *Type of siding: 7'_11 °Heating: tech c *Cooling: <br /> *Date of sale: Li-2-20zO *Sales price: /5;661) *Includes land:❑Yes $No <br /> DEALER INFORMATION(if no dealer,leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> AI/ ukty5 ihnrjchiYS 110 90 ihrve-y St. SE <br /> Homes /1 SD FL-kA, ,kfkrsept, off° q7,552. <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):Leon W 1 sbN Deal gnature: Date: <br /> 411, Ways 11aau> uta */Dmfs G � ril, , -Z Zozc <br /> TRANSPORTER INFORMATION(If not moving,leave blank) <br /> Transporter name: Transporter address and phone: • <br /> 440-2952(7/19/COM) Page 2 <br /> 440-2952(7/I9/COM) Page 5 <br />