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5I \ hJ)ESo,iem TT3O5 <br /> 1394229 <br /> NATURE OF FILING (check all that applies) .° <br /> u Change security interest 0 Change ownership ❑Demolition Date of demolition: <br /> d' <br /> 0 Recording as rear property 0 Removing from real property status ►,;r rip permit LI Converted to storage <br /> 0 Other: <br /> APPLICANT INFORMATION <br /> ID Dealer/seller : I Q Lender El Escrow/title agent 0 Owner/buyer 0 Legal representative <br /> Name:David Thomas Leja and Jacqueline Ann Sparks <br /> Address(including city,state,and ZIP): 8121 72ND AVE NE SALEM OR 97305 <br /> Phone: <br /> Email: <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): 'DMV X-plate number(if known): <br /> MENA/(]Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> Eil Other: <br /> Manufacturer:CMH ,: Model: 72SSR28724AH20 Year:2020 <br /> Manufacturer serial number HUD number <br /> ALB03992280RAB <br /> *Number of sections: °.2 *Square footage: 19'14 *Number of bedrooms: 11 *Number of bathrooms: 2.: <br /> *Type of roofing: A 5'61'44' *Type of siding: L *Heating: E\ �, - *Cooling: <br /> �` ,.�L , Cooling: <br /> *Date of sale: l o -1t--2,01,0 *Sales price: /65 l y ? 00 *Includes land: U Yes ANo <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer l a-n,e-ainnb s Dealer address and phone: <br /> CLAYTON HOMES ALBANY,OR DLR #MSD195 1437 CENTURY DRIVE NE <br /> CCB #166990 , ALBANY OR 97322 <br /> • (541)967-8555 <br /> I 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 <br /> is made for use as evidence in court and is subject to penalty for perjury. <br /> Der name(print): Dealer signature: Date: <br /> rryl -1ctorrter toirt[hta <br /> TRANSPORTER INFOR ION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: el 43-1131-t- SS 01 <br /> (111/4k -\cv1 '355 .01, Hol 406 S t o 9131'1 <br /> 440-2952(7/19/COM) <br /> OR Title Application-10/2019-TideApp 11211 Page 2 004344167-00001 <br />