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1 45 A Al excly) vo s <br /> • NATURE OF FILING (check all that applies) <br /> SZAa se yin an ner 1❑ ' ' n Uate`e11deemmolliition: <br /> ■ :ecordi •:"real • ••e- t - oving om r property .tus CI Trip permit ‘El' on e• d or ge <br /> ❑'other: <br /> APPLICANT INFORMATION <br /> CI 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): I DMV X-plate number(if known): ` <br /> E <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> Other:Brand new home <br /> Manufacturer:CMH Model:55FWK24362AH22 Year:2022 <br /> Manufacturer serial number HUD number <br /> HER0333270RA NTA2098763 <br /> HER033327ORB NTA2098764 <br /> *Number of sections:2 *Square footage:864 *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:8/25/21 *Sales price:105462 *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 /> ❑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 5',25 '2~Z <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 />