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{ <br /> i <br /> - \ g.: 21tD, 5,e_A, ,,,V) s c;ir-, 03 5 R 61 IJE S it Vel/LI ; <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> -' .' New home to MHODS t v o- . 5N1wner, 8lit'Ioy cp t. <br /> MVO/Ow-RA- ,f e i a C k '.s $.e <br /> UVINPrelrost-ItaLA NAYA�r AVA9 is efs 1s 0 Trip Permit <br /> r� �,,t��l�r sktrgeP <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> • _ . 0 Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name:J&M;Homes LLC Phone:541=928-1.47.1_::.. <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#: . N I A OR No Home ID: ❑New Home ❑Out of state home El Leaving County Deed Records <br /> Manufacturer:CMH 6 bC.C)9' - <br /> Model:55CRC28603AH23 Year:2023 `� <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> HER0337000RA <br /> HER0337000RB ..._- ... ._. <br /> - #of Sections: 2 - Sq.footage: 1620 Bedrooms: 3 Bathrooms: .2 <br /> __Roofma e:. Architectural. b typ Siding type: Vertical Wood Heating type: Electric. Cooling type: -None <br /> - Date of sale: : . _ <br /> 4/13/23 Sale price: 182179 Includes land: ❑Yes li "" `�` <br /> afapplicable) ❑No <br /> SECTION 4 DEALER INFORMATION(leave blank if no dealer) <br /> Name:J&M Homes LLC License#: SD155 <br /> Ursl, middle,last) M <br /> Address:15850 S Pope Lane <br /> City: 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 underst, d it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature: ,_ /yYl, ) Date: 6///2, 3 <br /> SECTION 5 HOME LOCATION <br /> Current Address:400 W Elm Ave <br /> City:Hermiston County:Umatilla State:OR Zip;97838 <br /> Park Name: (if applicable) <br /> ❑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:12242 Selah Springs Rd NE <br /> City:Silverton County:Marion State:OR - Zip:97381 <br /> Park Name: (f applicable) <br /> ❑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 />