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a00 i c . ncc 5 r OR - SE `7 a�evvi g73t7 <br /> Authentisign ID:B45936B3-2C90-EF11-8473-002248299057 <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> ❑� New home to MHODS er1.14L> ilite: ) <br /> ‘121,/asedil%rMetle a MA44,AtteSt6Vdrafe <br /> 'E fi1zf io heolge v s Di Trip Permit <br /> rl�u�644.,15)t it nce 1:2"\0 i ek i e): <br /> SECTION 2 APPLICANT INFORMATION (please rint) <br /> 0 Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal-Representative <br /> Name:COMMONWEALTH HOMEOWNER SERVICES Phone:503-244-2300 <br /> (first,middle,last) <br /> Address:18150 SW BOONES FERRY ROAD <br /> City:PORTLAND State:OR ZIP:97224 <br /> Email:M ELISA.000K@CWRES.COM <br /> SECTION 3� - HOME INFORMATION,(information in boldris required) <br /> Home ID.#: OR No Home ID: 0 New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:PALM HARBOR 6 I I Q 5 5 <br /> Model:310PL15401A Year:2025 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> PHH3100R24-16128A ORE 564599 <br /> #of Sections: 1 Sq.footage: 672 Bedrooms: 1 Bathrooms: 1 <br /> Roofing type: COMP Siding type: LAP CEMENT Heating type: ELECTRIC Cooling type: NONE <br /> Date of sale: <br /> a applicable) "1- 5 Sale price: -) ,0 t‘-1 Includes land: ❑Yes 0 No <br /> SECTION 4. `:.. -` DEALER INFORMATION(leave blank if no dealer) <br /> Name: . License#: <br /> first,middle,last) <br /> Address: <br /> City: State: ZIP: <br /> Email: Phone: <br /> I hereby declare 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 or my interest in it. The information listed is true to the best of my knowledge and <br /> belief,and I understand it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature: Date: <br /> SECTION 5 HOME LOCATION <br /> Current Address:3737 PALM HARBOR DRIVE <br /> City:MILLERSBURG County:LINN State:OR Zip:97321 <br /> Park Name:(if applicable) ❑This is a dealer lot or storage facility <br /> ❑This home is being moved to a new location Complete the section below <br /> New Address:2200 LANCASTER DRIVE SE,SP.#7A <br /> City:SALEM County:MARION State:OR Zip:97317 <br /> Park Name: (if applicable) SUNDIAL MHP ❑This is a dealer lot or storage facility <br /> Transporter Name:NEWMAN'S MOBILE HOME TRANSPORT Phone:503-932-5142 <br /> Address:PO BOX 236 City:SILVERTON State:OR <br /> Email: <br /> Page 2 <br />