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SECTION 1 ,NATURE OF FILING (check all that apply) <br /> \A/^ n L� �� r �,/�,dc�aroli n ) <br /> X Used home sale F -ReN crtito.citel r f{jy f( c14'd5{�i ao ge • <br /> - <br /> 7 Security interest change 9 "orr a 6Neitksas <br /> SECTION 2. APPLICANT INFORMATION (please print) <br /> Dealer/Seller f I Lender I X 1 Escrow/Title Agent Owner/Buyer I ] Legal Representative <br /> '- - - Name: First American Title Insurance Company Phone:,(503)581-0555 <br /> (first,middle,last) 4_ <br /> Address: 777 Commercial Street SE, Suite 100 <br /> City: Salem State: OR ZIP:97301'' .. _ .. • <br /> Email: mgirod@firstam.com <br /> SECTION 3 HOME INFORMATION (information in bold is required) <br /> Home ID #: 227126 OR No Home ID: New Home Out of state home Leaving County Deed Records <br /> Manufacturer:Commodore t a cio a9 <br /> - Model:unknown Year:1979 <br /> Serial Number(s) HUD Label Number(s) *Required"if new home` <br /> -.PS8737 __ . . .. . <br /> #of Sections: 1 Sq.footage: 896 Bedrooms: 2 Bathrooms: 1 <br /> Roofing type: Composition Siding type: T1-11 Heating type: Electric Cooling type: None - <br /> hardwood . <br /> Date of sale: 1' 1 Sale price: 100,000.00 Indudes land: I f Yes - X - No <br /> (If applicable) <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 belief, <br /> 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:9874 Golf Club Rd #9 <br /> City:Stayton County:Marion State:OR Zip:97383 <br /> Park Name: (if applicable) Oak Estates MHP [ 1 This is a dealer lot or storage facility <br /> U <br /> This home is being moved to a new location Complete the section below <br /> New Address: <br /> City: • County; State: ( Zip: <br /> Park Name: (if applicable) This is a dealer lot or storage facility <br /> Transporter Name: • Phone: <br /> Address: City: State: <br /> Email: <br /> Page 2 <br />