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3 a 53 S1- mom -.#z.
<br /> SECTION NATURE OF FILIN4i(ilieck all[hat apply).
<br /> a New home to MI IODS ❑ Adding or removing a co-owner ❑ Dcmolititrn(Date: )
<br /> 0 Used home sale ❑ Recording as real property ❑ Converted to storage
<br /> ❑ Srcurity interest change ❑ Removing from real property status 'Trip Permit
<br /> ❑ Transfer by inheritance ❑ Other(please note);
<br /> SECT? APPLICANT INFORMATION (please print)
<br /> ®Dealer/Seller ❑ Lender ❑ Escrow/title Agent ❑Owner/Buyer ❑ Legal Representative
<br /> Name:
<br /> (irst nr/el le las) � h v..... Phone: '0 3_ 5��_ax
<br /> yam'i L.)
<br /> Address: O"7 t c— L1/4., Pt K t=1 E Ln S '
<br /> city: p0 eL r.L.A r..t a State• Cj,� 7IP: 9 7 z z
<br /> Email: S Io t.,., clan'r'zui(-e,;c, l vr.2. 9
<br /> SECTION3` - S._ y e) �Gis1n,cV C eti,�-i
<br /> HOME INFORMATION(information in bold is required)
<br /> 1lome ID#: OR No Home ID: rj New!tome 0 Out ofstutehome ❑Leaving County Deed Records
<br /> Manufacturer: r4E-6--�4,4v,61 to -D.'..'7-I
<br /> Model: . . I O_S P a -//, 2� Year ae� Io
<br /> Serial Number(s) HUD Label Number(s)*Required if new home
<br /> r fir)_z — 2-s©9 L,4rfc9
<br /> #of Sections: a Sq.footage: 42,513 Bedrooms: .2_ Bathrooms: 2
<br /> Roofing type: ecm, Siding type: /,.////.'2),47<, Heating type: L /et72/c Cooling type: N/A.
<br /> Date of
<br /> tic ate: // Sale price: 9 a Includes land: Yes 'To
<br /> (fappUc�ble) (�"��-,ZOZj p /�(o Od. ❑ 4y "
<br /> SECTION 4 D_ EALER INFORMATION(leave bla0 if no dealer)
<br /> Name:
<br /> (first,middle, last) S rs i .: C<sL7a,� / 4""4-7, I License#: 0,?
<br /> Address: .94,/d , - Ss 44 4
<br /> 1
<br /> City: Srii&"Le/• 4N State: O 2 ZIP: 9 yg'78,'
<br /> Email: cS/ic�r�r ' ¢ /i c f .ar,-,-`-s- 99/ �[7i f7i� . �o:yr Phone: �-v 5_s d a 7oDn
<br /> I hereby declare this manufactured structure is free and clear of all mortgages,deeds of trust,security interests,andliens. [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 /> CD <� Date: to -3,' -a a Z S
<br /> SECTION,5 , HOME LOCATION .
<br /> Current Address: to SS— ;f nn 7_ J✓v_SS 4/
<br /> City: jcj 6.42i) County: ,%ar�,„,t.! State: D/Z. Zip:
<br /> Park Name: (ref applicable) arhis is a dealer lot or storage facility
<br /> This home is being moved to a new location Complete the section below
<br /> New Address: 3 .S3 7'arrr i.„rl ,cicc
<br /> City: _57,44...,E,77 County: 'l4 zi o,c1 State: C2 s Zip: 9-7 3 a 5—
<br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility
<br /> Transporter Name: 0e7t/,1.)e r - 7j .,-,sp,?/ v Phone: S`z-3�7 /.,�5-
<br /> Address: '1d 41,,,r;LlG)tJr 13�;)r�n if/ City: F.¢6�E ,4,,,,-, State: Q
<br /> Email: yDif �' lle4.,�,r.JCTre ,e.oi,r/
<br /> Page 2
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