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-_ NATURE OF FILING (checkall'that applies) u <br /> ❑ <br /> Cha nterest ❑ Ch ge- up" ition: <br /> ❑ R rty ❑ Ro, ;egp4 :s ❑■ Trip permitonv r e <br /> APPL'IdANT lPIFORItiIIATION <br /> Q Dealer/seller ❑ Lender ❑ Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name:J & M Homes, LLC <br /> Address(including city,state,and ZIP): 12901 SE 97th Ave. #100 Clackamas, OR 97015 <br /> Phone: 503-908-8166 <br /> Email: apowell@jandmhomes.com <br /> H <br /> OME INFORMATION:(* required) `� `�� <br /> Home ID number(if known): DMV X-plate number(if known): <br /> E (V13 55(0-15 <br /> n Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> n Other: <br /> Manufacturer:CMH MFG West, Albany Model:DRM 483F Year:2018 <br /> Manufacturer serial number HUD number <br /> ALB0380630RA <br /> ALB038063ORB <br /> *Number of sections:2 'Square footage: 1296 *Number of bedrooms:3 *Number of bathrooms:2 • <br /> *Type of roofing:Comp *Type of siding: T1-11 *Heating:Electric *Cooling: None <br /> *Date of sale:07/09/2018 *Sales price: $74,395.00 *Includes land: ❑ Yes ❑l No <br /> DEALEITINFORMATION,(if no dealer,leave blank) `• <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> J &M Homes, LLC MSD155 2109 SE 97th Ave.#100 <br /> Clackamas, OR 97015 <br /> ❑�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. <br /> I hereby declare that the above statement is true to the best of my knowledge and belief,and that I understand it is <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name (print): Del r si ature:C.� Date: <br /> J &M Homes, LLC � �-/7!/P <br /> TRANSPORTER INFORMATION (ifs not moving, Iea�e b ank) <br /> • <br /> Transporter name: Transporter address and phone: <br /> J &M Homes, LLC 12901 SE 97th Ave. #100 Clackamas, OR 97015 <br /> 440-2952(7/17/COM), Page 2 <br />