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5 -Cuo004) SECTION.1, NATURE OF,FILING(check all that apply) [/New home to MHODS ❑ Adding or removing a co-owner ❑ Demolition(Date: ) ❑ Used home sale ❑ Recording as real property ❑ Converted to storage ❑ Security interest change ❑ Removing front real property status g-Trip Permit ❑ Transfer by inheritance ❑ Other(please now): SECTION 2 APPLICANT INFORMATION(please print) ®Dealer/Seller ❑Lender ❑Escrow/ Title Agent ❑Owner/Buyer ❑Legal Representative Name: Phone: ca,3. $I first,middle last ;4 4- Address: 67/ S- b/4, e-;cr�-G0 S-r" City: /L State: cam!` ZIP: ' Email: `tea/ I ko,.-�s 9 tt e . FOR A SECTION 3 HOME INTION(information inbold is..required) Home ID/1: W OR No Home ID: ❑New Home 0 Out of state home ❑Leaving County Deed Records Manufacturer. ., Co ' 30a Model: 2,0( u 4 3 a Year: ola Serial Number(s) HUD Label Number(s)*Required if new home C4v2/e) ,oe. s- .2 s'O2 S`4 �',a�p.Z/D 8/22S- ,2c7) 2S_13 49k(:. '5-6&77 #of Sections: 0,2- Sq.footage: /p Bedrooms: 3 Bathrooms: Z Roofing type: "1 Siding type: //‘;,,e0;,04,h 4e._ Heating type: Ez&-G L Cooling type: /JD gip .4_ Date of sale: (Ifapplicable) &-2g.2,Z_ Sale price: ga? 20d, eV Includes land: ❑Yes Le No O SECTI N 4 DEALER INFORMATION blank if no dealer) Name: JJp (first,middle,last) c$K e/� t0'/�-,c]/. Je License#: t�� /' Address: •'i/2 SC City: 6. ,�.9/1/,- State: P}7'�__ ZIP: 9.7.57? Email: .5 -get.eJzie7 hrts, 994zo Coei, - Phone: 7D -5'02-706r I hereby declare this manufactured structure is free and clear of all mortgages,deeds of trust,security interests,and liens. I have the legal right to sell this manufactured structure or my interest in it.The information listed is true to the best of my knowledge and belief,and I understand it can be used as ev' ce in court and is subject to a penalty of perjury. Signature: c%p I Date: -2 -20 lc. SECTION 5 `HOME.LOCATION Current Address: a(�,S S �,•t,�,,1}`;5 fv,�r� City: A., t> /jct,t?/U County: /Pk/L/6k) State: p„L Zip: 97674 Park Name:(if applicable) ❑This is a dealer lot or storage Facility This home is being moved to a new location Complete the section below New Address: 3/R S� fwoo, 21/2 AJ City: S/f-L - County:4/4/e/j74,/ State: dz'12 Zip:9-7_3c./ Park Name: (if applicable) ❑This is a dealer lot or storage Facility Transporter Name: oc s 5 S obi-(,, 1 _ Phone: S o�- 7 99 3s Address: //�6 9Z City: sir,nt:tezz State: dv Email: 449. aC 1, I)f- £L. I t Page 2