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721166/- )( SE/ <br /> _ \ <br /> i 9 de <br /> NATURE OF FILING (check all that applies) • <br /> aCharigezeei4it sterest ji Change ownership • !1- : . -on ' -: <br /> Recordin alai-pupa y i P - : •: • al • .i .- • 0 Trip permitri o storage <br /> E Other: <br /> APPLICANT INFORMATION <br /> ❑ Dealer/seller ❑Lender ❑ Escrow/title agent ❑ Owner/buyer y ❑ Legal representative <br /> Name: ()CAL q UL7Q, . r\ <br /> Address(including city,state, and 7.1P): l a Coq D \ R i� <br /> Phone: <br /> Email: <br /> HOME INFORMATION (*required) <br /> Home ID number(ifknown): DMV X-plate number(if known): <br /> -0-1 •-5OZ3 <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: 16175( Model: Year:i P g.,3 <br /> Manufacturer serial number HUD number <br /> Ds-r-cK a-8ky f 9777 A <br /> *Number of sections: *Square footage: 108.0i *Number of bedrooms: *Number of bathrooms: a <br /> *Type of roofing: Cc/`",1, ^ *Type of siding: _Uj *Heating: Cle_e_.T *Cooling: <br /> *Date of sale: 3 ,,N7 Zq *Sales price: *Includes land: ❑Yes 111.,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 /> *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): Dealerms- - • e: Date: <br /> Doug Walton S Cef) — – <br /> TRANSPORTER INFORMATION (if nt 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 /> 1 <br /> 440-2952(7/19/COM) Page 2 <br /> l'd 66Z I.-OOZ-£09 eo1AaeS ewoH ellgoW s6noa d017:170'OZ 90• <br />