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(J030` .5 - S LSE .y n5 . b p. 35g <br /> NATURE OF FILING (check all that applies) <br /> (� _• se• ty '.. -res- ip uo scte ., �..�.; .,• <br /> h •- or...I_as e. p •• • y P • -'•• ing :`n r-. ope 0 Trip permit NALviele.41,69e <br /> Other: <br /> APPLICANT INFORMATION <br /> ❑ 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 /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> n Other:Brand new home <br /> Manufacturer:CMH Model:72PAR28563GH22 Year:2022 <br /> Manufacturer serial number HUD number <br /> ALB0416580RA <br /> • <br /> • <br /> ALB041658ORB <br /> *Number of sections:2 *Square footage: 1512 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Electric *Cooling:None <br /> *Date of sale:9/21/21 *Sales price:149436 *Includes land: ❑Yes Q 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): De er signatur : Date: <br /> J &MHomes, LLC 6/Q�a � <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 />