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<br /> - co►���I� s-I- N E— ,e/,CF N /
<br /> SEC'tiON `I
<br /> NATURE OF FILIN0.(ch&k all that apply)
<br /> �.__b New home to MHODS ❑ Adding or removing n co-owner ❑ Demolition(Date: _'_)
<br /> _______ ❑ Used home sale ❑ Recording as rent property ❑ Converted to storage
<br /> ❑ Security interest change ❑ Removing from real property status Trip Permit
<br /> ❑ Transfer by inheritance ❑ Other(please nate):
<br /> - ION TIN E . .
<br /> APPLICANFORMA TIOIV(ple
<br /> S aseprint)
<br /> Dealer/Seller ❑ Lender ❑Escrow/Ttle Agent ❑Owner/Buyer ❑Legal Representative
<br /> Name: ►� I hone:-.G - "0..--)aaer
<br /> nsl.mid.�l� ►v�c�`�"O
<br /> Address:
<br /> ( D `71 a,�tc� 0 � � P
<br /> City: ` c, State: 04 ZIP: 7ZzS�
<br /> Email: Via ciao-reze-ivecfinze,r " 9Vo0(;s,,,,.`rt<...pC of.,,,
<br /> SOON.3 -HOME INFORMATION(Information in bold i0equired)
<br /> Home ID#: OR No Home ID: in New Home 0 Out of stale home 0 Leaving County Deed Records
<br /> Manufacturer: r.t LO 1 •)-T7 5
<br /> model: 10EVau436" Year: a S-
<br /> Serial Number(s) HUD Label Number(s)*Required if new home
<br /> e4vaidCA23 — 2-507aA '1e& S6P94/.7
<br /> �' AtL2l D _ 7 i DP, l�/Z S—toG9�F
<br /> #:of Sections: 02 Sq.footage: % ,..2C,,' Bedrooms: 3 Bathrooms: ,
<br /> Rooting type: et. e Siding type: ( ,,c pc,,,,,k Heating type: e bete.,*. Cooling type: ti—4
<br /> Date of sale: a Sale price: ( 'i em Includes land: ❑Yes .�No
<br /> (�f4r�PlicableJ (P Zo Z S `, 49.0,
<br /> SECTION 4 - DEALER INFORMATION`(leave blankif no dealer) _ ,
<br /> Name: License#: c2,09
<br /> �rst.middle.last) la•., .Lei , i—✓ ' c)2, G-i�c, C=—S
<br /> •
<br /> Address: gild j&--- (5.,v��i 4.,_A_)
<br /> City: #�4..n4-A./ State: '2 L ZIP: i'73 7e
<br /> Email: /" I 0n- 1 g/'� Phone:
<br /> �+7.Pri�G..1 t'�r�Q �1a[HeS ��� {-�lvt.C.[c. . �6�-r
<br /> I hereby declare this manufactured structure islfree 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 un it can be u videlce in court and is subject to a penalty of perjury.
<br /> Signat e: o Date: ?_i — ?a 'S.`
<br /> SECTIONS _. m_ . H LOC
<br /> ATION _ _
<br /> Current Address: ,a cps— P-op--eSS 4/Al
<br /> City: v.) . I County: jt/I C_i ;er..t State. p,P Zit. 9 7v 7
<br /> Park Name:(IIf 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: 3 a a3 co",be,--- .s iT /(J6—
<br /> City: 5ttL n'I County: li��z ei ddl State: �� Zip:•7 3Q 5—
<br /> Park Name:(f applicable) ❑This is a dealer lot or storage facility
<br /> Transporter Name: gtr tiNc T T -,PA,, yn, - Phone:
<br /> Address: 5/e,,9 I/61I4M /f?w;1 l2Gl/ City: 6-',}cc� R„ _ State: Oe
<br /> Email: /d.P co /.�° 'A/Al r-r r 6 i1�_.-c
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