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3 9 & 5Ave_ M , U CI <br /> NATURE OF FILING (check all that applies) • <br /> h,te3,A\ir.ity-Xptast I ] Change ownership 1 •e`+t int R L:e 0 .em. i• : <br /> e I a s I 0 Trip permit I o e age <br /> 'e ,.b nga ° p ' <br /> [tier: <br /> APPLICANT.INFORMATION <br /> 0 Dealer/seller I ❑Lender E Escrow/title agent I ❑ Owner/buyer I ❑ Legal representative <br /> Name:J&M Homes <br /> Address(including city,state,and ZIP):12901 SE 97th Ave, Suite 100, Clackamas, OR 97015 <br /> Phoe•503-908-8166 <br /> n . <br /> Email:tmelchior@jandmhomes.com <br /> • <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> kiEvi 6200 -79o <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> Q Other:Brand new home <br /> Manufacturer:CMH Model:72D RM28443AH21 Year:2021 <br /> Manufacturer serial number HUD number <br /> ALB040282ORA <br /> ALB040282ORB <br /> *Number of sections:2 *Square footage:1404 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Gas *Cooling:None <br /> *Date of sale:1/8/21 *Sales price:108900 *Includes land:❑Yes Ej 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 /> DI 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): Dealer signature: Date; <br /> J& M Homes, LLC ei( 14►v '>- 3 (7 Z <br /> 3C2/ <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/CONI) Page 2 <br />