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. 4.7 <br /> Cr Aro 3c 5 <br /> NATURE OF FILING (check all that applies) <br /> Lq ' h: of it . • to t % Ch..-:e ► . •rs`• a •- o' o D. = of mlo 'on. <br /> ''Rec ng as protremo 1 r eal per ktes El Trip permit [ Cerw8pteage <br /> L- ther: <br /> APPLICANT INFORMATION <br /> II 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 /> 1� CaO (6)-E <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:55CRC28483AH21 Year:2021 <br /> Manufacturer serial number HUD number <br /> HER0328480RA NTA2032883 <br /> HER0328480RB NTA2032884 <br /> *Number of sections:2 *Square footage:1280 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Electric *Cooling:None <br /> *Date of sale:2/2/21 *Sales price:121878.00 *Includes land: ❑Yes 1=I 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): Dealer signature: Date; <br /> J&M Homes, LLC' got,: <br /> ; 74 0 <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 />