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SGcs O9 4t, <br /> NATURE OF FILING (check all that applies) <br /> ■ .. _e ;c in .1., ❑ •A, ow,e °. I-\,lo 1 '.• •. Yht iai <br /> -c. di : as•e. .ro r- o 'n . •'' r-: . s•- . . •• 0 Trip permit � d torage <br /> t r: <br /> APPLICANT INFORMATION <br /> ❑■ Dealer/seller ❑Lender ❑Escrow/title agent ❑ 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 /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> 0 Other:Brand new home <br /> Manufacturer:CMH Model:55FWK28563BH20 Year:2020 <br /> Manufacturer serial number HUD number <br /> HERO31964ORA ORE550896 <br /> HER031964ORB ORE550897 <br /> *Number of sections:2 *Square footage:1493 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood. *Heating:Electric *Cooling:None <br /> *Date of sale:12/19/2020 *Sales price:106757 *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): De�signature. Date / <br /> J &M Homes, LLC G k- J 41/5402 <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(7119/COM) Page 2 <br />