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, i,. 52186 A nolev-50 n USE , A <br /> j i., - ---.,- <br /> ,, <br /> Lc,,„s, P <br /> _SECTION 1 NATURE OF FILING (check all that apply) _ <br /> ` o1124 4 A ' a r ) <br /> Ue\ys d a a d' a ed to storage .• <br /> eta 'n to .olSie e ' g pe status LI Trip Permit <br /> TZI/V- s inlfelitance '--"faller note • <br /> SECTION 2 APPLICANT INFORMATION (please print) .. . <br /> ❑Dealer/Seller ❑Lender 0 Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name'J&M• Homes LLC Phone:541-928=1471 - <br /> Urst,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#: N C OR No Home ID: ■❑New Home El Out of state home D Leaving County Deed Records._ <br /> _ _ Manufacturer:CMH Co 0 B .3. .l• .— <br /> _ <br /> Model:72DRM28563BH22 Year:2022 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> • . ALB0419200RA NTA2120899 <br /> ALB041920ORB NTA2120900 <br /> ._#of Sections:• 2 Sq.footage: 1512 Bedrooms: 3 Bathrooms: 2 <br /> Roofing type: Architectural Siding type: Vertical Wood Heating type: Electric Cooling type:,..None,::... <br /> . <br /> ,. Date of.sale: 7/10/23 Sale price: 135655 Includes land: El Yes 0 No <br /> - . ...gapplicableJ <br /> SECTION 4 DEALER INFORMATION (leave blank if no dealer) <br /> Name'J&M Homes LLC License#:MSD155 <br /> Psi,middle, last) <br /> Address:15850 S Pope Lane <br /> City:Oregon City State:OR ZIP:97045 <br /> Email:dasia@jandmhomes.com Phone:503-908-8166 <br /> —f 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: ( b/ Date: ?/?Y/2 J <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) ❑■ This is a dealer lot or storage facility <br /> M This home is being moved to a new location Complete the section below <br /> New Address:5486 Anderson Rd SE <br /> City:Aumsville County:Marion State:OR 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 />