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, ._____________________L___________j=____________, 004 vei115_e_305-44
<br /> : SECTION 1 NATURE OF FILING(check all that apply)
<br /> Q New home to Ml IODS ❑ Adding or removing a co-owner ❑ Demolition(Dale: )
<br /> ❑ Used home sale ❑ Recording as real property ❑ Converted to storage
<br /> ❑ Security interest change ❑ Removing from real property status i} '(rip Permit
<br /> El Transfer by inheritance El Other(please note): -t
<br /> SECTION 2 APPLICANT INFORMATION (please print)
<br /> [j'Dcalcr/Seller ❑Lender ❑EscrowTtic Agent ❑Owner/Buyer ❑Legal Representative
<br /> Name: •/
<br /> (first, middle Jest) I x'n,-)A) Phone: .5Z^2 -2 5�
<br /> Address: /v•-7/ bUa?6C�Git:. ✓2 -F----
<br /> City: 7 0 State: „c_____' ZIP: 9 7Z.?S
<br /> Email:5-11�&1....1,p f4a2. lizwi' iS/e)eGu-,4r(._..0 Cc,din__
<br /> SECTION 3 HOME INFORMATION (information in bold is required)
<br /> Home ID II:, N VI ) OR No Home ID: Ncw!-tome 0 Out of state home El Leaving County Deed Records
<br /> Manufacturer: „G&.e„ 7,-, o/J 40 l a-a.7(p
<br /> Model: a/,,
<br /> LC z y G� Year Da SP
<br /> Serial Number(s) HUD Label Number(s)*Required if new home
<br /> - -2-/, ' - 2 VAs`7/4- D/�E-- ..5-6,4?
<br /> zit) t,‹- ,_,7 c< c-s`-7 d D4! 5 E ,Pe) l
<br /> #of Sections: Sq.footage: /p..Z , Bedrooms: 3 Bathrooms: V---
<br /> Roofing type: ae,-4,c, Siding type: ; Heating type: .(z' Cooling type:
<br /> Date of sale: (�
<br /> (tjappl cable) ID 27'ZJ Sale price:/ ,� .. Includes land: ❑Yes ----No
<br /> SECTION 4 DEALER INFORMATION(leave blank if no:dealer)
<br /> ` Name:
<br /> (first,middle.last) Sf�E.ei/J,s'-tJ /�-----,�.2G� j License#: a
<br /> Address: 9 4 S , ' �/440/-7 c,
<br /> City: S -�,-,,,lj I State: f3,�_ ZIP: ' )--73-7(.S.4
<br /> Email: .�r-- „ a , /76a'izl4.''9 e.6in�zi4. . C Phone: S"-b 3-S7a—7d
<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' be used as evident 'yrt and i ubject to a penalty of perjury.
<br /> Signature: L-..2 I Date: le/vs _.2 S
<br /> SECTION HOME LOCATION
<br /> Current Address: .,76:,s---S_ 6P,z)„,,-,pss Ge_J
<br /> City: le-ter-ev 4/56c,+e✓c.1 I County: 421;Z I State: d7� I Zip: 9767/
<br /> Park Name: (if applicable) !This is a dealer lot or storage facility
<br /> g This home is being moved to a new location Complete the section below
<br /> New Address: .3p,CC .5-e(Gc*«Qp 7 //i
<br /> City: cJ 1-, '"--71,-1 County: /,,"/{-,r/Q;v l State: E7Z___. I Zip: 7 7 '< —
<br /> Park Name: (f applicable) ❑This is a dealer lot or storage facility
<br /> Transporter Name: ��,Gic/C '7" 7, ,g,LI5iad,,, ,--- �J Phone: k75'- 3 S-r
<br /> Address: Z /� 9 47/ i�.r /.�,:eze i gib City: L���/�f via State: (; .'
<br /> Email: (/a1 i ,, -rv"ib pe-z04-1
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