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NDA-h rook Rd S E Lyons <br /> SECTION 1 NATURE OF FILING (check all that apply) <br /> CrAyaviatzk o IISx.ebWner of <br /> 11, rc <br /> S tiiri a change 131....R n Qyhere m ,odiNwerEtty status 0 Trip Permit - <br /> 'cl/Xpufgfer b l e a \ aDtl(k(ple se rbde).: <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> 0 Dealer/Seller 0 Lender 0 Escrow/Title Agent 0 Owner/Buyer ❑Legal Representative <br /> Name:J&M._Homes LLC Phone:541-928-1471 <br /> Ursl,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#: OR No Home ID: 0 New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:CMH ( t' e9 L8 S <br /> 1Vlodel: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 0 No <br /> (Ifapplicable) <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 /> 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 understa it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature: Otk, y►Zf)41 Date: 5 Jf 3A3 <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) ❑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:22988 North Fork Rd SE <br /> City:Lyons County:Marion State:OR Zip:97358 <br /> Park Name: (f 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 /> • <br /> Page 2 <br />