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1 3 r, sr Sree-A el 5 G 7 34(e . <br /> SECTION 1 NATURE OF FILING (check all that apply) <br /> 4 YADAI liVA tgNzs i ' c mer rilAkzAti n a . . . ) . <br /> VNicad.icaneNl4 e m e [ a1 a tl'kvsfdsa = <br /> - tl , e 112Neni king fl'9x � 0 Trip Permit _ .. .-- <br /> _ SECTION 2 APPLICANT INFORMATION (please print) <br /> ❑■ Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative , <br /> lvame•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:lsimon@jandmhomes.com . <br /> SECTION 3 HOME INFORMATION (information in bold is required) <br /> Home ID#: OR No Home ID: ❑■ New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:CMH & 0 7 I 01 ;.. <br /> Model:72DRM28483CH23 Year:2023 <br /> Serial Number(s) HUD Label Number(s)*Required if new home , <br /> ALB0424370RA NTA2171196 . • - - • - <br /> . ALB042437ORB NTA2171197 - - <br /> #of Sections:' 2 •• Sq.footage: 1512 Bedrooms: 3 Bathrooms:. 2 . - .... <br /> Roofing type: Architectural Siding type: Cement Lap Heating type: Electric Cooling type:- Heat Pump <br /> - Date of sale: 11/6/22 Sale price: 139678 Includes land: ❑Yes No <br /> (If applicable) <br /> SECTION 4 • DEALER INFORMATION(leave blank if no dealer) <br /> Name:J&M Homes LLC License#:MSD155. <br /> (first,middle,last) <br /> Address:15850 S Pope Lane . <br /> • <br /> City:Oregon City State:OR ZIP:97045 .. . - <br /> . . .Email:dasla@jandmhomes.com Phone:503-908-81.66. . ._ .. . <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,i d it can be sed as evidence in court and is subject to a penalty of perjury. <br /> Signature: tL ?�� Date: 6 j?/ <br /> SECTION 5 HOME LOCATION . . <br /> Current Address:33213 Hwy 34 SE <br /> City:Albany County:Linn State:OR Zip:973'22 <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:133 Fir Street <br /> City:Gates County:Marion State:OR Zip:97346 <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 />