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5 <br /> k <br /> cld ) U L1 .. <br /> O <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> V A • or ovi co- r eni�tiet'(D�te�� <br /> ] ec e c in s re op rty yn ces'ti st age <br /> ect; .iut rt ife emo • g fr rea o y atus 0 Trip Permit <br /> ansfet 'til'ien'tRnce •.i-• F..- e •le): <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> 0 Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Omer/Buyer ❑Legal Representative <br /> Name:J&M Homes LLC Phone:541-928-1471 <br /> (first,middle,last) <br /> Address:33213 Hwy 34 SE <br /> City:Albany State:OR ZIP:97322 <br /> Email:Isimon@jandmhomes.com <br /> SECTION 3 HOME INFORMATION (information in bold is required) <br /> Home ID#: E OR No Home ID: 0 New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:CM H (v CO 5 (04 [53 4uQo� <br /> Model:72DRM14601 BH23 Year:2023 <br /> Serial Number(s) HUD Label Number(s)*Required if new-home <br /> ALB042277OR <br /> #of Sections: 1 Sq.footage: 854 Bedrooms: 2 Bathrooms: 2 <br /> Roofing type: Architectural Siding type: Vertical Wood Heating type: Electric Cooling type: None -- <br /> Date of sale: rice:1 OI27I22 Sale <br /> (If applicable) P 88725 Includes land: ❑Yes 0 No <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name.J <br /> (first,middle,last) &M Homes LLC License#:MSD155 - <br /> Address:12901 SW 97th Ave, Suite 100 <br /> • <br /> City:Clackamas State:OR ZIP:97015 <br /> Email:dasla@jandmhomes.com Phone:503-908-8166 <br /> I hereby declare 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 or my interest in it.The information listed is true to the best of my knowledge and <br /> belief,and I understand it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature:�j(9'Z�.• �-y�v� Date: .(2/6/R.:3SECTION 5 "`���///. HOME LOCATION <br /> Current Address:33213 Hwy 34 SE <br /> City:Albany County:Linn State:OR Zip:97322 <br /> Park Name: (if applicable) 0 This is a dealer lot or storage facility <br /> 0 This home is being moved to a new location Complete the section below <br /> New Address:12384 West Stayton Rd • <br /> City:Aumsville County:Marion State: 0 R Zip:97325 <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name:J&M Homes LLC p Phone: 541-928-1471. <br /> • Address:33213 Hwy 34 SE City: Albany State: OR <br /> Email:Isimon@jandmhomes.com <br /> Page 2 <br />