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\59Bq GkY s S � 4 ,-Nr) 1-9 <br /> NATURE OF FILING (check all that applies) <br /> L h.,_• ecb 'n - S- .1_- •• --rsh . De-.lite.- ►: eo :-mo `.'• <br /> [� ^ :c.•:in g as r,al bre•-rty Rei e '-g fr.I, .ea e .pe i tat s ■❑Trip permit NacolN,tetilizfitaage <br /> NAker: <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 knotivn): DMV X-plate number(if known): <br /> (J0 0. 3 <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:55CRC28483AH22 Year:2021 <br /> Manufacturer serial number HUD number <br /> H ER033073ORA <br /> HER033073ORB <br /> *Number of sections:2 *Square footage:1280 *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:4/22/21 *Sales price:133604 *Includes land: ❑ Yes EI 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 /> I 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 signature: Date: <br /> J & M Homes, LLC /20/7").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 />