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fl e <br /> . ice481t 0 I a St • <br /> ..1617150 <br /> SECTION 1 NATURE . <br /> OF FILING(check an that apply) <br /> o A d <br /> U om she Re (Nuarkpalwrap3rtyrte to.., . .ge . • <br /> S 'ty' rest ov ea erty status ®'Trip Permit • - <br /> ' r tk5y�e C (p e): - <br /> APPLICANT.INFORMATION (please-print) <br /> I1 Dealer/Seller n Lender. [Escrow/Title Agent n Owner/Buyer f Legal Representative <br /> Name: <br /> H <br /> • (first middle last> G 1 a--Y I.°rs• onn es c.4 4I , 1541 - <br /> Address: (i:.{X c.o.,p-.,r y 6 r. 4/ N )� of I .�'SS. ' <br /> City: H G 6 �)� ZIP: ��,v. �- , State: I r 2 2 <br /> Email:. 0( p. Ct�,. P ., 1,1Q rh e S . co., ; <br /> SECTION 3 . .` HOME INFORMATION"(information in bold Is required) <br /> Home ID#:N E\itj OR No Home ID:fl New Home Out of state home El Leaving County.Deed Records <br /> Manufacturer: DRM484F 48tg pp <br /> Model:.72DRM28484DH25 '� .6 U <br /> IYear: --. : .2025 . - <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> ALB0442160RABAC <br /> ##of Sections: "'2, Sq.footage: I,14 Bedrooms: o� •Bathrooms: <br /> Roofing type:A.cl, S1,:, Siding type:L AS�►ari . Heating type:. 6( 2 ... <br /> Date of sale. Cooling type,. <br /> Date <br /> ofsalapplicable) t/�t���,� Sale price: if(C I /Cy Includes land: 17 Yes o ' '' +., <br /> SECTION 4 . <br /> - Name:_ _, <br /> DEALER INFORMATION (leave blank if no deader) <br /> CLAYTON HOMES ALBANY,OR <br /> (first middle,last)" . . . I <br /> License <br /> Address "143'7 CENTURY DRIVE NE <br /> City: ALBANY <br /> I State: OR ZIP 97322 <br /> Email: 1.1c.G I t; 6,( oo, W w, . G o r, <br /> Phone: (541)967-8555 <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: • <br /> y Cam,--c'-'_"'� Date: /(/7 <br /> ;SECTION 5 ' : " <br /> : HOME LOCATION a <br /> Current Address: 2l.,L hac.F. r &1�� <br /> City: ,4( County: j..,,. 6. I State: (j a I Zip: 4'X t _ <br /> Park Name:(fapplicable) <br /> (—This is a dealer lot or storage facility <br /> J This home is being moved to a new location Complete the section below <br /> New Address: I y ell G Id .a L vv.h l ,j. S <br /> City: ,s- ,fo vu I County:/14c.r-r o.-. I State: 0 I Zip: q7 ea <br /> Park Name:(f applicable) fl This is a dealer lot or storage facility <br /> Transporter Name: it.ev► < F `rr,,,c,k2 T.1- r <br /> Address: g' °i'r� 0 Phone: ��I a 71 3 y W y. <br /> C11y: C�L P iia H.e. I State: A/C, - <br /> Email: YGr' 6es►rle P��• GGr.n <br /> 440-2952(11/22/BCD) Page 2 <br /> OR Title Application-9/2024-TitleApp11211 <br /> 005013445-00003 <br />