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• <br /> E"--7 a (ta -70 A-q-e LA9c39 �- <br /> NATURE OF FILING (check all that applies) <br /> l'ap ec i -r• i. o L-0e.. it . D..- .f• u of u <br /> s e lope f re 1 r a El Trip permit [�t Nato <br /> tlAth%- <br /> APPLICANT INFORMATION <br /> 0 Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑Legal representative <br /> Name:J 8,0\11 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 /> NES C11()351 � <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming put of county deed records <br /> n Other:Brand new home <br /> Manufacturer:CMH Model:72ING28703AH21 Year:2021 <br /> Manufacturer serial number HUD number <br /> ALB0412440RA <br /> ALB041244ORB <br /> *Number of sections:2 *Square footage:1944 *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:4/24/21 *Sales price:161202 *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 MSD155 12901 SE 97th Ave. #100 <br /> Clackamas, OR 97015 <br /> 503-908-8166 <br /> Millis manufactured structure is free and clear of all mortgages, deeds of trust,securityinterests,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 ,rn . 12/2„L4,/ <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 />