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. g 0 '3 'Korn S-1-- SE 2, <br /> Jon) <br /> NATURE OF FILING (check all that applies) <br /> C'..n_e -c ty Ate -st ge c -ersh'.- L ?Ora to a : R de - ltio• . <br /> te.ore'n_as -al .rop \ s -mevi•_ fr.a r=.l .- _ .tus ■❑Trip permit [p, v d o ate <br /> her: <br /> APPLICANT INFORMATION <br /> 0 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 /> 83(4 0 <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:55CBC28483AH22 Year:2022 <br /> Manufacturer serial number HUD number <br /> HER0332450RA <br /> HER033245ORB <br /> *Number of sections:2 *Square footage:1280 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Electric *Cooling:None <br /> *Date * 139426 *Includes land: Yes ■ No <br /> of sale:6/24/21 Sales price: ❑ ❑ <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:Q/,�V�1 <br /> J &M Homes, LLCC;f0.A.1 /O �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 />