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a5o Ose--1-ro CR di SDe-Tiro ; .1- 9 734 <br /> NATURE OF FILING (check all that applies) <br /> u e se u ' t st o ip ition ate ma <br /> t.11-QcnKta ea a ro -rty * '< lovin• •o • r-:1 , . - s . ..s [a Trip permiton to storage <br /> ❑Other: <br /> APPLICANT:INFORMATION. ! <br /> ❑■ Dealer/seller <br /> ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑Legal representative <br /> Name:J &M Homes LLC <br /> Address (including city,state,and ZIP):12901 SE 97th Ave. #100 <br /> Phone:503-722-4500 <br /> Email:salesservice@jandmhomes.com <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Et ( 03, 2) <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: Coming out of county deed records <br /> ❑ <br /> ❑Other: <br /> Manufacturer: 3Q . Model. # v Year:a( <br /> •Manufacturer serial number HUD number <br /> ALB41 0750RA <br /> ALB410750RB <br /> *Number of sections:2 *Square footage: 1512 *Number of bedrooms: 3 *Number of bathrooms:2 <br /> *Type of roofing:Comp *Type of siding:Lap *Heating:Electric *Cooling:None <br /> *Date of sale:6/10/2021 *Sales price:180,000.00 *Includes land: ❑Yes [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 /> 503-722-4500 <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): Dea signature: <br /> �► Date: <br /> J &M Homes LLC ( (gen—/./ <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 /> 503-722-4500 p i <br /> 440-2952(7/19/COM) Page 2 <br />