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ID- <br /> 7(6 5 on ; \--0%r Mc ,e Rci k)E 0 <br /> Co at lucky <br /> NATURE OF FILING (check all that applies) <br /> )♦, ,- ecr it iIt:, es I e ip R aem• ion ate em ion: <br /> '-'I/INc.• (It• .s al . s. '~mo g • r-. ,.rt. - s ❑■ 'Trip permitr d s l <br /> APPLICANT.INFORMATION - <br /> El Dealer/seller. ❑Lender Cl 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 j <br /> Phone:503-722-4500 <br /> Email:salesserviceoc@jandmhomes.com <br /> HOME INFORMATION {* required) <br /> Home ID number(if known): e,\ DMV X-plate number(if known): <br /> fr <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:CMH Golden West-Albany Model:The Buster SP28562F Year:2022 <br /> Manufacturer serial number HUD number <br /> *Number of sections:2 *Square footage:2130 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Comp *Type of siding:Lap *Heating:Electric *Cooling:None <br /> *Date of sale:5/16/2021 *Sales price:181,715.00 *Includes land: ❑Yes *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 /> OThis 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 -riLv' A .1- 2 , <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(7/17/COM) Page 2 <br />