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I e.6 5 G MCI S-i,. A k,cyy, s 0 o 1, IC <br /> Docusign Envelope ID:23419788-209B-4385-86DA-B6B161ElAFAB <br /> 76U4b51 <br /> SECTION 1 NATURE OF FILING(then....ii that apply) <br /> NytkbpflredenielDS I d r g i -owner of tie ate. ) <br /> ISI.Sr— resale Rec ad' eriy . v to e <br /> g <br /> rr seataffite 1K Re v Inc,.,ire s ('>Tf Trip Permit - <br /> g em a 'ice d . rSp'""' "J): f\ , <br /> SECTION 2 APPLICANT INFORMATION (please print) . <br /> rl Dealer/Seller n Lender f Escrow/Title Agent JXI Owner/Buyer ("Legal Representative. <br /> Name: _ <br /> (fast,middle,last r' r� { � -��'� , <br /> ) 1 j 1)d�,�t' 1, 1 0.1 T .�`A 1 I f ''n (t/";il_ 1 Phone /_;y:F; <br /> ICE. ����(;C1'� 1� � "f <br /> Address: �'_)F..1r5'1 7 ` 1\- i r I m `r . t,'J �-,�' <br /> City: �:�1�'3s�1 I �� � �:� _ ti � �_ t.? <br /> Email:. State: 1. 1 ZIP: t, . 'z <br /> SECTION 3 HOME INFORMATION (information in bold is required)gaited) <br /> Home ID it: ; OR No Home ID:®New Home [Out of state home Ei Leaving County Deed Records <br /> Manufacturer: SKYLINE MCMJNNVILLE . <br /> Model: WEST RIDGE CrJ a C)f O:. <br /> LYear: 2023. <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> 245000011A101342AB <br /> #of Sections: �} Sq. <br /> 4�-�—• footage: <br /> 1 0'-� Bedrooms: �, Bat6l;oorns• <br /> Roofing type:,('1.{ 1 Siding type: vfpd Heat <br /> Date of sale; j �type: .�Z�JkI�� C� Cooling type: 1 .. <br /> (If applicable) (( I?s Sale price: )(4 J c 75° includes land: E Yes r'.No <br /> SECTION 4 DEALER INFORMATION (leave blank If no dealer) . <br /> Name: CLAYTON HOMES ALBANY, <br /> ((bst,middle,last) O R License It: <br /> Address: 1437 CENTURY DRIVE NE <br /> City: ALBANY I State: OR I <br /> ZIP: 97322 . <br /> Email: I Phone: (541)967•8555 <br /> j'1 e� : J" 6YY� ,C:I'YYl <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 and cos andtit can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature: Ot)11t tt(j g Dat�t'9/2025 <br /> SECTIO Uv n �,� � ,,Ltx ... . <br /> HOME LOCATION <br /> Current Address: (4.37 b '° 7$6— <br /> YY , <br /> City: .A(b?u.dl, I County: 1`l.A) State:& I Zip: ai 73 2-2 <br /> Park Name:(f applicable) r-This is a dealer lot or storage facility <br /> This ho <br /> me is being <br /> emg moved to a new location Complete <br /> p ere the section below <br /> New Address: J)(1 fib Afee ri) .'.-- <br /> City: .4 1 9 °I I i A `r <br /> (if Pp (.�' county: i �+.).I( �`�) ( state: I'Zip�`�1���j <br /> Park Name: i applicable) f—This is a dealer lot or storage facility <br /> Transporter Name: � . r `i'" y _ Phone: <br /> Address: �?O �qui R. City <br /> NLt.YlP State: A (1y <br /> Email: . <br /> 4_,&(_5 •03'_4 <br /> 440-29520 1/22/BCD) Page 2 <br /> OR Title Application-9/2024-TitleApp11211 <br /> 004966077-00002 <br />