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Aug 14_20,03:29p Dougs Mobile Home Service 503-200-1299 p.2 <br /> NA 1 uric Ln- t-lLINi (Cnecle an mat applies) <br /> ftiAatfige,,‘NEKsintsiest j Change ownership �„D 't' n a o e olition: <br /> n as en in nm pr rty status titt Trip permit lapazota.tet ragt <br /> ❑ er: <br /> APPLICANT INFORMATION <br /> ❑ Dealer/seller ❑Lender 0 Escrow/title agent 5r1 Owner/buyer ❑ Legal representative <br /> Name: DOu W <br /> Address(includingity, state,and ZIP): <br /> Phone: <br /> Email: <br /> HOME INFORMATION (*required) <br /> , Home ID number(ifknown): DMV X-plate number(if known): <br /> c:1 1Q irr\t3a 55� <br /> ❑ Moving in from another state <br /> Has no home ID or X-plate because: El Coming out of county deed records <br /> ❑ Other: <br /> • <br /> Manufacturer. clue I Model: V,�\�Q 41 Year: 1 <br /> Manufacturer serial number. • HUD number <br /> s`r cR,00\3 t s s\°\ <br /> *Number of sections: J *Square footage: 9 Q *Number of bedrooms: 3 *Number of bathrooms: .{ <br /> *Type of roofing: CelYY *Type of siding: ` \_ll 0. , a *Heating: N,c.tAk Q;r *Cooling: <br /> *Date of sale: 6"---141—,, *Sales price:l 1, *includes land: ® Yes IllkNo <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> "V J� h I / - -� ad‘/O- Fry�f <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 ( ()j — A. Dealer signature- Date: <br /> TRANSPORTER INFORMATION (if not owing, leave blank) <br /> Transporter name: Transporter address and hone: �a3�j3 <br /> 6/1e_ C h eep : t 2 q Iret <br />