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. , 555S \`ine coi 8 , 9 -730 (0 <br /> NATURE OF FILING (check all that applies) <br /> nre 1 e a •sh VA •l' io b. • :e et : <br /> �V-i�/� � <br /> ;,: o d ., . . • ••• A ■ ' ;y• i•E re" e„, ••e s •.s il Trip permit �d\p, �r <br /> e <br /> APPLICANT INFORMATION <br /> ❑■ Dealer/seller ❑ Lender ❑ Escrow/title agent El Owner/buyer ❑ Legal representative <br /> Name:J &M Homes, LLC <br /> Address(including city, state, and ZIP): 12901 SE 97th Ave #100 <br /> Phone:503-908-8166 <br /> Email:bbaxter@jandmhomes.com <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> ME VI ►M 3 51-1 Co o) <br /> ❑ Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> ❑ Other: <br /> Manufacturer:Golden West Model:DRM481 F Year:2019 <br /> Manufacturer serial number HUD number <br /> ALBO385000RA <br /> ALBO385000RB <br /> *Number of sections:2 *Square footage: 1,296 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:arch shingles *Type of siding:smart panel *Heating:elect *Cooling: <br /> *Date of sale:02/02/19 *Sales price:$80,914.00 *Includes land: El Yes ❑■ 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 /> ❑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): Dealer signature: Date: <br /> TRANSPORTER INFORMATION (if not moving, leave,blank) <br /> Transporter name: Transporter address and phone: <br /> J & M Homes, LLC 12901 SE 97th Ave #100 <br /> Clackamas, OR 97015 <br /> 440-2952(7/17/COM) Page 2 <br />