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S 1-11/4y S V uLD0octiou_fi <br /> SECTION 1 NATURE OF FILING (check all that apply) <br /> El New home to MHODS ❑ Adding or removing a co-owner ❑ Demolition(Date: ) <br /> ad° Used home sale El Recording as real property El Converted to storage <br /> El Security interest change ❑ Removing from real property status fe Trip Permit <br /> El Transfer by inheritance El Other(please note): <br /> SECTION 2 • APPLICANT INFORMATION(please print) <br /> El Dealer/Seller El Lender ❑Escrow/Title Agent Owner/Buyer El Legal Representative <br /> Na <br /> (first,middle,l st) C-U l l . l 13 a '?0 6 C f Phone j 3 -7/ p6 21- <br /> Address: /o Z�S r r IS 64 Q r,4 S <br /> City: 77)f fl�'( Q State: 0 j ZIP: 993 9 Z <br /> Email: i 0,13 <br /> Ye2tA.ej` U�,L'O. C p y✓i <br /> SECTION 3 HOME INFORMATION (information in bold is required) <br /> Home ID#: 24S 9 9's OR No Home ID: ❑New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer: ! I(0 7 <br /> Model: Ig r O h, Crrr Year: <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> bg 'LeincigA /1-q15 Bile) 1e. 2bbq,GS <br /> #of Sections: / Sq.footage: 92 y Bedrooms: Bathrooms: Z <br /> Roofmg type: Come as j t oyl Siding type: .j _ Heating type: t l ectir i L Cooling type: <br /> Date of sale: <br /> (ifapplicable) 3-2I-2 02S Sale price: rYee. Includes land: El Yes 121<lo <br /> SECTION 4 DEALER INFORMATION.(leave blank if no dealer) <br /> Name: <br /> (rst,middle,last) License#: <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: 7 )7 E loo,r t(S A d S s e.c .1/ <br /> City: !v, c a n 004 f County:(Po j y State: DC Zip: 9'7,0/ <br /> Park Name:(if applicable) pi o yl m Y 1 O U� ) it a g '. Li c ❑This is a dealer lot or storage facility <br /> ❑This home is being <br /> " moved to a new location Complete the section below <br /> New Address: / 0 (p S SO Ut Al(I 1 S QO‘C # l <br /> City: 1/0o d too- n County:At, l'0>1 State:b Zip:q7 c?1 <br /> Park Name:(if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name: L al PC(261, �Yi-I— C o vls4YU - 1 0 ( 0 Phone:S 03 r? O 024 <br /> Address: I b 1:1-c `Pal eT'c 6c �City7U f n e ( State: o K e c1 b Yl . <br /> Email: (� Y e2�e l\� , Cowlyvix <br /> Page 2 <br />