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35 ) 15 Nor-i-kVoti 'k Re) sc 2-N) b s 9 '1358 <br /> NATURE OF FILING (check all that applies) <br /> FA • s•c4 i i, e , t • g- • - • le L -raitia1/4../bgte'aLkrekridlitigte171,AAAA.." <br /> ikAstOkiaznAND2OV4 ' o e• -r 1=1 Trip permit FAZiefckt‘l N.,gfo\alk_ <br /> V3t'DeF4-- <br /> APPLICANT INFORMATION <br /> El Dealer/seller Ej Lender ['Escrow/title agent Owner/buyer Legal representative <br /> Name: J &M Homes, LLC <br /> Address(including city,state,and ZIP):12901 SE 97th Ave.#100 Clackamas, OR 97015 <br /> Phone: 503-908-8166 <br /> Email: tmelchior@jandmhomes.com <br /> • HOME INFORMATION ("` required) , • <br /> Home ID number(if known): a DMV X-plate number(If known): <br /> N Ev./ (a 000-1 3 <br /> El Moving in from another state <br /> Has,no home ID or X-plate because: Li Coming out of county deed records <br /> El Other:Brand new home <br /> Manufacturer:CMH Model:55CRC28483AH21 Year:2021 <br /> Manufacturer serial number HUD number <br /> HER0327860RA <br /> HER032786ORB <br /> *Number of sections:2 *Square footage: 1280 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Electric *Cooling:Heat Pump <br /> *Date of sale:10/10/20 *Sales price:122637 *Includes land: E]Yes 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): Deal r signature: • Dat : <br /> J &M Homes, LLC 3 ///202/ <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(7/17/COM) Page 2 <br />