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g,0-1 .16 ,4IH p cta t3' 61 klg S of �'1; l/5 q-73.75 <br /> NATE OF FILING (check all that applies) <br /> 7J fan ec int e C e -rtrs p y/ tie oli 'o at of of J <br /> \c—Acs din real Ay..., v re 1 pr rt t�dt"� 0 Trip permit ` ve ed orage <br /> APPLICANT INFORMATION <br /> ❑Dealer/seller <br /> Lender ❑Escrow/title agent ❑ Owner/buyer E 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:503-722-4500 <br /> Email:salesserviceoc@jandmhomes.com <br /> HOME.INFORMATiON (*required) <br /> Home ID number(if known): DMV X-plate number(if known): 6703665__ 6 <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ❑ Other: <br /> Manufacturer:Golden West Model:Dream year:2022 <br /> Manufacturer serial number HUD number <br /> ALB0415520RA NTA2094902 <br /> ALB041552ORB NTA2094903 <br /> *Number of sections:2 *Square footage:1296 *Number of bedrooms:3 *Number of bathrooms:2 <br /> . *Type of roofing:Comp *Type of siding:Vertical *Heating:Electric *Cooling:nN/A <br /> *Date of sale:7/15/2021 *Sales price:$95,099.00 *Includes land: ❑Yes J 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 12109 SE 97th Ave <br /> Clackamas, Oregon 97015 <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): Deal signature: 704A Date: <br /> J&M Homes,LLC �- �,f ,�� 4/7/2022 <br /> l.S� LLL <br /> TRANSPORTER INFORMATION (if not:moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> J &M Homes,LLC 12109 SE 97th Ave <br /> Clackamas, Oregon 97015 <br /> 440-2952(7/19/COM) Page 2 <br />