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Ia (054 \N0Oci <br /> NATURE OF FILING (check all that applies). <br /> aloSheftessavrityintereir 0 Change ownership L r ' . ' '• . s. a- - . 1 ': . <br /> iZ,Noift.as-real%propezly e g r tus ■❑Trip permit o a.stera e- <br /> ier: <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller ❑Lender ❑Escrow/title agent Owner/buyer ❑ Legal representative <br /> Name: 61, Q J cA,I, <br /> Address(including city,state,and ZIP): <br /> Phone: <br /> Email: <br /> - . r - HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> n/P, m3(ob3 cop <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: cu_e_,r- y, Model: Yea/7(1913 <br /> Manufacturer serial number HUD number <br /> 6 Q.5 ro a-43 1 s6 <br /> *Number of sections: j *Square footage:616 *Number of bedrooms: 1 *Number of bathrooms: <br /> *Type of roofing: C;,,,,".,, *Type of siding: *Heating: *Cooling: ,9. <br /> *Date of sale: 83—"� a� *Sales price: *Includes land: 0 Yes ❑No <br /> DEALER INFORMATION (if no dealer,`leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> Dougs Mobile Home Service INC 652 12692 Fry RD NE Aurora OR <br /> 97002 503-799-0539 <br /> 0 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 s'•:•. It-: Date: <br /> Doug Walto d% CMCJ- Q:3 02-e-3?ct <br /> TRANSPORTER INFORMATION (if of moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> Dougs Mobile Home Service INC 12692 Fry RD NE Aurora OR 97002 503-799-0539 <br /> 440-2952(7/19/COM) Page 2 <br />