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n 5 E TE1, rn t -r392 <br /> SECTION 1 NATURE OF FILING (check all that apply) <br /> \Sewliptue-te-14171(30-5- EINA6ntorlerrivriNg41-eis-oVtier ) <br /> 1=1-‘pststkiartveNalrx, UrtittP6WeAtoaAP615e4tY 5Apoetd jkAsterage <br /> • ehpfcjh QjaTherty1atusEI Trip Permit <br /> \Ffikitergre~tattoe 1124)&7521e2irot& <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> - 0 Dealer/Seller 0 Lender El Escrow/Title Agent El Owner/Buyer 0 Legal Representative <br /> Name:J&KHomes LLC Phone:541-92871 471(iirsl,middle', las° <br /> Address:33213 Hwy 34 SE <br /> City:Albany State:OR ZIP:97322 <br /> Email:lsimon@jandmhomes.com <br /> SECTION,3 • HOME INFORMATION (information in bold is required) <br /> Home ID#: OR No Home ID: 0 New Home El Out of state home El Leaving County Deed Records <br /> Manufacturer:CM H (7N-1 ( D- ) <br /> Model:72ING42603AH23 Year:2023 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> - ALB0423940RA NTA2163451 <br /> ALB042394ORB NTA2163452 • • - <br /> ALB0423940RC NTA2163453 <br /> #of Sections: 3 -- " Sq.footage: 2360 Bedrooms: 3 Bathrooms: 3— - <br /> —Roofing type:i Architectural Siding type: Vertical Wood Heating type: Electric Cooling.type: None <br /> • <br /> --- :Date of sale. 2/14/23 <br /> Sale price: 236918 Includes land: El Yes No <br /> (Ifapplicable)• <br /> SECTION,4 DEALER INFORMATION(leave blank if no dealer) <br /> — • <br /> Name' <br /> (first middle J&M Homes LLC License#:MSD155 <br /> , ,las° <br /> - • •Address:15850 S Pope Lane <br /> City:Oregon City State:OR ZIP:97045 <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 unders nd it can,be used as evidence in court and is subject to a penalty of perjury. <br /> h c2/,73 <br /> Signature: t r <br /> . )'yky-Y) Date: <br /> SECTION 5 HOME LOCATION <br /> Current Address:2445 Pacific Blvd SW <br /> City:Albany County:Linn State:OR Zip:97321 <br /> Park Name:(if applicable) 0 This is a dealer lbt dr storage facility <br /> . , ft This home is being moved to a new location Complete the section below . • •. <br /> New Address:6217,Stayton Rd SE • <br /> City:-Turner County:Marion State:OR Zip:97392 <br /> Park Name: (if applicable) El 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 />