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77610 Marion Pds�, <br /> NATURE OF FILING (check all that applies) <br /> ►I . _ _ c i . e g s p i : 'ii '.n • . : of•em. 1 .n: <br /> V\Ad' r pr e o n fr a o atus ❑� Trip permit o d t torage <br /> APPLICANT INFORMATION <br /> 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:bbaxter@jandmhomes.com <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> N Ew m 358839 <br /> ❑Moving in from another state <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:72DRM28483CH19 Year:2019 <br /> Manufacturer serial number HUD number <br /> ALB039261 ORA <br /> ALB039261 O RB <br /> *Number of sections:2 *Square footage:1296 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Electric *Cooling:None <br /> *Date of sale:10/22/19 *Sales price:78767 *Includes land: ❑ Yes EU 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): Dea9&'? <br /> r signature: Date: <br /> J & M Homes, LLC _ a' i 2. <br /> // <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> 440-2952(7/17/COM) Page 2 <br />