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, I MOrc4b <br /> 13'11 R vey RA NE , Ce_roa; <br /> ATURE;OF FILING (check all that applies) <br /> iane-seClit3erderest ", Change ownership a :emolit`.s D. of de on: <br /> agssordiEmAraTpreprerty a t . ovi=.l i' e. :. statusTrip permit nveri �n-stefage <br /> te . / � <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name: 41 d/'y L- L4 C o S <br /> Address(including city,state,and ZIP): /3 7(0 / /- d, / v�/ <br /> Phone: G-3-5-67.- 5-90 <br /> Email: Pe rr 1 L c V/S rho// L e-veil <br /> ".HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 31 057 P.) k 8/ <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> AOther: <br /> Manufacturer: ifi514-6rd Model: UA -n Q vil V Year: I 7 7 <br /> Manufacturer serial number HUD number <br /> 0 S d(o O 3 LAX U ,(l K-i4 ow✓1 <br /> *Number of sections: L. *Square footage:J3 q y *Number of bedrooms: 3 *Number of bathrooms: L <br /> *Type of roofing:eWh pc.silx i *Type of siding: 1_01 Yn e4 I *Heating: 1-}-ca�-p"A n *Cooling:1-M2 /1 u sn <br /> *Date of sale: *Sales price:-e- *Includes land: ❑Yes ►�/ No <br /> • DEALER INFORMATION;(if no 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 /> jaS®� ttc� l�Yl <br /> 6-13 - `1g3 - y33q <br /> 440-2952(7/19/COM) Page 2 <br />