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15 Ce v Lo 81 3 4 (4 <br /> NATURE OF FILING (check all that applies) <br /> ►! • -ge .e ri 'nte :t \ ' h.,g, 0 n• 1. gero an r o'..- .. i . .... <br /> NI,A42x0 i .s •3+ p ••e I! -r o i 6.•- • stalls El Trip permit IV i•,' ett'{tto"te <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller ❑Lender . ❑Escrow/title agent 0 Owner/buyer ❑ Legal representative <br /> Name:J& M Homes <br /> Address(including city,state,and ZIP):12901 SE 97th Ave.#100 Clackamas, OR 97015 <br /> Phone:503-908-1866 <br /> Email:tmelchior@jandmhomes.com - <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> 00 I <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: [' Coming out of county deed records <br /> ❑■ Other:Brand new home <br /> Manufacturer:CMH Model:72DRM28443AH21 Year:2021 <br /> Manufacturer serial number HUD number <br /> ALB040357ORA <br /> ALB040357ORB <br /> *Number of sections:2 *Square footage:1350 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:Metal *Type of siding:Vertical wood *Heating:Electric *Cooling:None <br /> *Date of sale:11/23/20 *Sales price:104238 *Includes land: ❑Yes 0 No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> J & M Homes, LLC MSD155 12901 SE 97th Ave. #100 <br /> Clackamas, OR 97015 <br /> 503-908-8166 <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 my knowledge and belief,and that I understand it is <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name (print): Deale signature: Date: <br /> J &M Homes, LLC , 3/, _DZ/ <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> J & M Homes, LLC 12901 SE 97th Ave.#100 <br /> Clackamas, OR 97015 <br /> 503-908-8166 <br /> 440-2952(7/19/COM) Page 2 <br />