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\BA 5 Fe.Irr,j ( n qi3b <br /> NATURE OF FILING (check all that applies) <br /> 9N9 url i er t Thai geavrs ' emo 'x� eNiaaY of oliti <br /> ec r ' a e <br /> pt/IpNty'cfia v'.g r 1 o r a us ❑■ Trip permit Uelskaventataraige <br /> IRAker: <br /> APPLICANT INFORMATION <br /> 0 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 /> NEW C0004-7 6 <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:72DRM24503AH21 Year:2021 <br /> Manufacturer serial number HUD number <br /> ALB0408220RA NTA2035190 <br /> ALB040822ORB NTA2035191 <br /> *Number of sections:2 *Square footage:1182 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical cement *Heating:Electric *Cooling:Heat.Pump <br /> *Date,of sale:9/19/2020 *Sales price:96883 *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 <br /> 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 �(, <br /> Fly/2d,2/ <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 />