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5 ad-ion <br /> 1 . 0-38 ,4 1 RA <br /> ),-unisu , <br /> tie <br /> SECTION 1 NATURE OF FILING (check all that apply) <br /> `atgiv e31 A or ovt co- r emo t(D< <br /> ] e e c in s re op rty kEZZS n�c t t ge <br /> ecturi 1iuu rut shanfe emo ' g fr rea •o atus 0 Trip Permit <br /> .� ansfet ' entance [ tlt ''] e tst'e ete): <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> •Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> name•J&M Homes LLC Phone:541-928-1471 <br /> (first,middle last) <br /> ) <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 /> I-Iome ID#: J 6 Vv OR No Home ID: ❑■ New Home ['Out of state home ❑Leaving County Deed Records <br /> Manufacturer:CMH Co v &)5-(04 t/53 46gUA <br /> Model:72DRM 14601 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 /> Roofmg type: Architectural Siding type: Vertical Wood Heating type: Electric Cooling type: None <br /> Date of sale: 10/27/2.2 Sale rice: <br /> (If applicable) p 88725 Includes land: El N No <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name:J&M Homes LLC License#:MSD155 <br /> Urst,middle,last) <br /> Address:12901 SW 97th Ave, Suite 100 <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: //bjg2L �, . -y04/ Date: "2/6/;Z 3 <br /> SECTION 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 /> •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: O R Zip:97325' <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name:J&M Homes LLC Phone: 541-928-1471 <br /> • Address:33213 Hwy 34 SE City: Albany State: OR <br /> Email:Isimon©jandmhomes.com <br /> Page 2 <br />