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f 5O Cad d Avc 5 , er� <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> ❑ New home to MHODS ❑ Adding or removing a co-owner ❑ Demolition(Date: ) <br /> ❑ Used home sale ❑ Recording as real property ❑ Converted to storage <br /> ❑ Security interest change ❑� Removing from real property status ❑� Trip Permit <br /> ❑ Transfer by inheritance ❑ Other(please note): <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑■ Owner/Buyer ❑Legal Representative <br /> Name:PauI Gregory Duchateau Phone:503-508-6108 <br /> (first, middle, last) g ry <br /> Address:1506 62nd Ave SE • <br /> city:Salem State:OR zIP:97317 <br /> Emaii:pgdcase@gmail.com <br /> SECTION 3 HOME INFORMATION (information in bold is required) <br /> Home ID# OR No Home ID: ❑New Home ❑Out of state home WLeaving County Deed Records <br /> Manufacturer:Karstan Homes ( 1)C) "7'3 <br /> Model:SE-SE06 Year:2004 <br /> Serial Number(s) HUD Label Number(s) *Required if new home <br /> TKCSTOR330426509 <br /> #of Sections: 3 Sq.footage: 2600 Bedrooms: 2 Bathrooms: 2 <br /> Roofing type: Comp Siding type: Lap Heating type: Gas Cooling type: HP <br /> Date of sale: 8/15/2021 Sale price: N/A Includes land: ❑Yes ❑No <br /> of applicable) <br /> SECTION 4 „ DEALER INFORMATION (leave blank if no dealer) <br /> Name: License#: <br /> (first, middle, last) <br /> Address: <br /> City: State: GIP: <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 /> SECTIONS HOME LOCATION <br /> Current Address:5042 Hayesville Dr NE <br /> city:Salem county:Marion State:OR zip:97305 <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> ❑� This home is being moved to a new location Complete the section below <br /> New Address:1506 62nd Ave SE <br /> city:Salem county:Marion State:OR zip:97317 <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 />