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IU <br /> Docusign Envelope ID:230AD05E-FO6C-40AGBC14-5E1C087EOEFE <br /> p NE, Si' <br /> 1626272 . <br /> SECTION 1 NATURE OF FILING (check all that apply) ,{� , .r-- r 1 0 r ��R � _ ). <br /> ( -�u�cef e s age <br /> \I F` ci a sta Trip Permit <br /> Nf '. ►iii:b .`' ri • Ce e l o <br /> SECTION 2. <br /> APPLICANT INFORMATION (please print) :" <br /> Dealer/Seller n Lender. Escrow/Title Agent f Owner/Buyer n Legal Representative <br /> Name: <br /> (first middle,last) <br /> ,o <br /> Address: . <br /> City State: ff .. . <br /> } ZIP: r <br /> Emaail. s <br /> SECTION . 0` . <br /> HO E INFORMATION (information in bold is required) <br /> Home ID/# OR No Home ID:❑New Home 0 Out of state home 0 Leaving County Deed Reco <br /> rds <br /> Manufacturer DRM481M 48 u i,,9 8 ' - <br /> Model: 72DRM14482AIR25 1Year. 2025 <br /> Serial Number(s) I HUD Label Number(s)*Required if new home <br /> ALB044513ORAC <br /> #of Sections Sq.foot . : <br /> Roofin e age: Bedrooms: <br /> g typ , to Siding type- Beating type:_` Bathrooms: <br /> Cooling. type t <br /> Date of sate: M .. <br /> Sale rice Yes No <br /> (Ifappllcable) P Includes land:, n (- _... . , <br /> SECTION 4 = DEALER INFORMATION (leave blank it no dealer) `- <br /> Nauie <br /> CLAYTON HOMES ALBANY,OR Li a �J�g gry <br /> (lima,middle,last). 1f"dVfSD1 5 <br /> LR <br /> Address:.1437 CENTURY DRIVE NE .L tr„ () .*:•• <br /> City:` ALBANY State: OR ZIP. 97322 <br /> Email .{r((1, '� �I C I i td, i 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 Mite N'Q� Date: 8/27/2025" <br /> SECTION b4' `".' OME LOCATION _ <br /> Current Address: . 'c 1 ( , f P t , <br /> City: - �y "� County: 1 . 1 State: WW.. Zip.173 <br /> Park Name:(if applicable) - [This is a dealer lot or storage facility <br /> r This home is being moved to a new location Complete the rectum below <br /> New Address: 4 0 / , — „ <br /> . <br /> City. I LI = t county: all`a : = . state. . zil 7381 <br /> Park Name:(f applicable) J`This is a dealer lot or storage facility <br /> Transporter Name: i Phone541.. 7Q_q0 f 4(, <br /> Address: ,C ; ,4" t(I 'Ii ty: State: <br /> Email: <br /> - 1' ' 40 1 i ,vr -d ' tara,� <br /> 440 2952(11/22/BCD) Page 2 <br /> OR Title Application 9/2024-TitleApp11211 005052442-00002 <br />