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, . 4-7 3 0 AQ,\01.,(yr1 54,1„evy) 9.-130 <br /> NATURE OF FILING (check all that applies) <br /> Chai _- -ecurit t Cha owr ip D- . rtion irate : en * ' 'on. <br /> e.: •in,:s re • : et s; o ro ' eal . opei - st.''s ❑1 Trip permit ao <<Je <br /> th r: <br /> APPLICANT INFORMATION_ <br /> 111 Dealer/seller n Lender ❑Escrow/title agent ❑ Owner/buyer y 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): r_ DMV X-plate number(if known): <br /> Nth • <br /> n Moving in from another state • <br /> Has no home ID or X-plate because: [1 Coming out of county deed records <br /> IN Other:New Home <br /> Manufacturer:CMH MFG, West Albany Model:SP2866F Year:2021 <br /> Manufacturer serial number HUD number <br /> ALB040434ORA <br /> ALB040434ORB • <br /> *Number of sections:2 *Square footage: 1,782 *Number of bed rooms:3 *Number of bathrooms:2 <br /> • <br /> *Type of roofing:Architectural *Type of siding:Cement Lap *Heating:Gas *Cooling:None <br /> *Date of sale:4/8/2021 *Sales price:$160,205.00 *Includes land: ❑ Yes El No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> J & M Homes, LLC MSD-155 12901 SE 97th Ave #100 <br /> • <br /> Clackamas, OR 97015 <br /> 503-908-8166 <br /> fThis 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: Da;e: <br /> J & M Homes, LLC ./1tl Pr/n 1 i - � . <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 Clackamas, OR 97015 <br /> 440-2952(7n9/Cony Page 2 • <br />