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� r <br /> 1 \ 39 6kCQLp E . Iz <br /> NATURE OF FILING (check all that applies) <br /> •.'_ •e, i .. et.`v.}.• n-rs ': i i a de i ' <br /> • s • . . ..-r, \ ' 11.0 r:. .,.,- 04,Al Trip permit o t <br /> El/3tJjer: <br /> APPLICANT INFORMATION <br /> Q■ Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer D 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:bbaxter@jandmhomes.com <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): A ' DMV X-plate number(if known):EW 3\5 B-3 OS <br /> 'V El Moving in from another state ' ' 1 <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> Q Other:Brand new home <br /> Manufacturer:CMH Model:72ING24362AH19 Year:2019 <br /> Manufacturer serial number HUD number <br /> ALB039199ORA <br /> ALB0391990RB <br /> *Number of sections:2 *Square footage:852 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Electric *Cooling:None <br /> *Date of sale:9/18/19 *Sales price:79863 *Includes land:❑Yes 0 No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> J &M Homes, LLC MSD155 12901 SE 97th Ave. #100 <br /> Clackamas, OR 97015 <br /> 503-908-8166 <br /> Li 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): Deal signature: Date: ,�/ /1 <br /> J &M Homes, LLC �i,�, I` ` I/s ) <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> 440-2952(7/17/COM) Page 2 <br />