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9538 Nb,,vh kP3 <br /> E typas <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> / e i 'till i I iwfil i of a <br /> KLAD tgm [ i� i�,i; i opejty ra - <br /> firi a e hange C9_liz k ii m tii)oerafy status ❑■ Trip Permit <br /> 'ci/Van feeB) [11/4.,t1A(p fte).: . <br /> SECTION 2 • APPLICANT INFORMATION (please print) <br /> N Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑OwnerBuyer 0 Legal Representative <br /> Name:J&M._ _ <br /> Homes LLC Phone:541-928-1471 <br /> Urst,middle,last) <br /> Address:33213 Hwy 34 SE <br /> City:Albany State:OR ZIP:97322 _ _ <br /> EmaihIsirnon@jandmhomes.com <br /> SECTION 3 • HOME INFORMATION (information In bold is required) <br /> Home ID#: OR No Home ID: III New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:CMH ( , � S <br /> Model:72DRM28563DH23 Year:2023 <br /> Serial Number(s) HUD Label Number(s)*Required if new home - <br /> ALB042803ORA - • . <br /> ALB042803ORB • <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 /> Date of sale: 8/16/23 Sale price: 153050 Includes land: ❑Yes ❑■ No <br /> afapplicable) <br /> SECTION 4 DEALER INFORMATION(leave blank if no dealer) <br /> lvame: <br /> first,middle,last)J&M Homes LLC • License#:MSD155 <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 it can be used as evidence in court and is subject to a penalty of perjury. <br /> ta � <br /> Signature: � ��'j Date: 2/j 3A 3 <br /> SECTION 5 HOME LOCATION <br /> Current Address:2445 Pacific Hwy SW <br /> City:Albany County:Linn State:OR Zip:97358 <br /> Park Name: (f 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:22988 North Fork Rd SE <br /> City:Lyons County:Marion State:OR Zip:97358 <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 />