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0-ObV-eAt in <br /> Au'et <br /> NATURE OF FILING (check all that applies) \ <br /> ecu • - est al: .nge o, • P. . • <br /> ec• :'.-_ e. pro:• • 'emov ' -. . .:. _ . . <br /> -0 Trip permit <br /> e . <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): (005020,Q' I <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:Champion Model:1222CT Year:2022 <br /> Manufacturer serial number HUD number <br /> 245-000-H-Al0.1290A <br /> 245-000-H-Al01290B <br /> '`Number of sections:2 *Square footage:1620 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Cemplank *Heating:Electric *Cooling:Heat Pump <br /> *Date of sale:3/9/22 *Sales price:204027 *Includes land: ❑Yes 0 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 /> Q 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 sibnature: Date <br /> J &M Homes, LLC ���,tA1 25--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 />