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�`3 ., s <br /> ti San .NCSE Sau-t, aA 7 3176 � <br /> SECTION,- NATURE OF FILING(check all that apply) <br /> ❑ New home to MHODS ❑ Adding or removing a co-owner ❑ Demolition(Date: ) <br /> ❑ Used home sale __ ❑ Recording as real property .❑ Converted to storage <br /> ❑ Security interest change ❑ Removing from real property status 0 Trip Permit <br /> ❑ Transfer by inheritance ❑ Other(please note): <br /> SECTION 2 APPLICANT INFORMATION(please_print). <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name:J and M Homes, LLC Phone:503-908-8967 <br /> (first,middle,last) <br /> Address:15815 S Pope Ln <br /> City:Oregon City State:Or ZIP:97045 <br /> Email:salesserviceoc@jandmhomes.com <br /> SECTION 3.. . : HOME IINFORMATION•(informationin:bold;is;required)` <br /> Home ID#: OR No Home ID: Q New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:Golden West-Albany <br /> Model:ING 601K Year:2024 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> ALB0435430RA <br /> ALB043543ORB <br /> ALB043543ORC <br /> #of Sections: 3 Sq.footage: 2347 Bedrooms: 3 Bathrooms: 3 <br /> Roofing type: COMP Siding type: Vert Heating type: ELEC Cooling type: N/A <br /> Date of sale: 3-24-2024 Sale price: 130470.00 Includes land: ❑Yes CI No <br /> nfapplicable) <br /> SECTION 4 ,-DEALER`INFORMATION-(leave blank if no dealer), ; <br /> Name: <br /> first,middle,last) License#: <br /> Address: <br /> City: State: ZIP: <br /> Email: Phone: <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 understand it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature: Date: <br /> ;SECTION 5 :HOME LOCATION <br /> Current Address: <br /> City: County: State: Zip: <br /> Park Name:(if applicable) ❑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: <br /> City: County: State: Zip: <br /> Park Name:(if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name: Phone: <br /> Address: City: State: <br /> Email: <br /> Page 2 <br />