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Oss ct CDC <br /> a-tq <br /> NATURE OF ft ING (check all that applies) <br /> c it er- I i,. rti.- ..te : d---oli ':n: 1/ ,- <br /> II'i '' o ' . o- ,. t 0 Trip permit NisAVett-tuskliNge <br /> [9tkber: <br /> APPLICANT INFORMATION <br /> El Dealer/seller ❑ 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, Clackamas,OR 97015 <br /> Phone:503-908-8166 <br /> Email:tmelchior@jandmhomes.com <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): ) DMV X-plate number(if known): <br /> -NEVI/ LOb4btL1 <br /> ❑ Moving in from another state 0514 U6)--) <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ❑ Other:New Home <br /> Manufacturer:CMH MFG, West Hermiston Model:Schult FWK 2848-C Year:2022 <br /> Manufacturer serial number HUD number <br /> HER0332490RA NTA2073588 <br /> HER033249ORB NTA2073589 <br /> *Number of sections:2 *Square footage: 1,280 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Composition *Type of siding:Vertical *Heating:Electric *Cooling:None <br /> *Date of sale:10/8/2021 *Sales price:$117,925.00 *Includes land: ❑ Yes 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 MSD-155 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 -I t '} aW <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> J&M Homes, LLC 12801 SE 97TH Ave.#100 <br /> Clackamas, Or 97015 <br /> 440-2952(7/19/COM) Page 2 <br />