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(,aq l 1,1 � 11.)t , 5&.l lqc-) 8 <br /> - M1I1W-rn Q11 LI IQG;Q�i t.I1t6.7, <br /> . 1\I11 V11L VI-: t-ILII\V��V � <br /> u ic i"l�ity nrntcst Change ownership ELDeoalif? n on: <br /> lig(5 ielf a TArty • r • • .roe' v.tlu.rs Trip permit T"'ett stoptrgc <br /> tr: <br /> APPLICANT INFORMATION <br /> ❑ Dealer/seller ❑ Lender ❑ Escrow/title agent ❑ Owner/buyer ❑Legal representative <br /> Name: o__e_ v Tudi <br /> Address(including city,state,and in* .0 . bC . U->l ; V\tLo L-) <br /> Phone: --0-6.-107-)1 • + l ! T <br /> Email)( I �� <br /> � . 1 Coterat <br /> HOME INFORMATION (* required). <br /> Home ID number W.known): DMV X-plate number(if known): <br /> 1 5-75 <br /> 7/ <br /> -Moving in from another state <br /> Has no home ID or X-plate because: n Coming out of county deed records <br /> ❑ Other: <br /> Manufacturer:nf - Model �1�� �i 11• Year: I� O <br /> Manufacturer serial number HUD number <br /> *Number of sections: ci *Square footage:Jit, *Number of bedrooms: 3 *Number of bathrooms: <br /> *Type of roofing: ecirry <br /> *Type of siding: ,�IYI,e, - r,, *Heating: itoc.4.4,- *Cooling: Aii„4 <br /> *Date of sale: L - j r•_1� *Sales price: *Includes land: Yes '57,1 No <br /> DEALER INFORMATION • <br /> (if no dealer;-,leave blank) .; <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> ❑.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. <br /> I hereby declare that the above statement is true to the best of niy knowledge and belief, and that I understand itis <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name (print): Dealer signature: • Date: <br /> TRANSPORTER INFORMATION (ifnot moving, leave blank). <br /> Transporter name: Transporter address and phone: <br /> (11 Ae-eVeS 1 P)ick-eAv tij- Po eo)( 3 t,i9714/ick eLoi <br /> 440-2952(7/17/COM) Page 2 <br />