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B/adael-e2Re. na/ 14-tubbIe-c., <br /> NATURE DEFILING.(check all that:'applies) <br /> : . <br /> ❑• h.. g= • ity it - Change ownership Demolit e o emo u ion: <br /> ❑ e rc s re roperts II Re + ro -. proper st.'_ 0 Trip oerm it'' Id ( •s e 0 a_: <br /> ❑Other: <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 /> HOMEINFORMATION (* rei i <br /> r uired) `: . <br /> Home ID number(if known : DMV X-plate number(if known): <br /> f -35-79®li <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> 0 Other:Brand new home <br /> Manufacturer:CMH Model:72GSA42724AH19 Year:2019 <br /> Manufacturer serial number HUD number <br /> ALB039207ORA <br /> ALB039207ORB <br /> ALB039207ORC <br /> *Number of sections:3 *Square footage:2940 *Number of bedrooms:4 *Number of bathrooms:3 <br /> *Type of roofing:Architectural *Type of siding:Lap *Heating:Electric *Cooling:Heat Pump <br /> *Date of sale:7/13/19 *Sales price:202498 *Includes land: ❑Yes El 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 /> 0 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): Deale signature: • Date/ <br /> J &M Homes, LLC <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> 440-2952(7/17/COM) Page 2 <br />