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Caoaa j Ge( . 5a,tei-Nrk <br /> • <NATURE OF FILING.(check all that apKies <br /> ❑ t 4 g: •`c,o ' y -re t' \ h:s le ow - ship el D-- olitio oa - • .e • ' io <br /> lI ' moo' ._.. :.� _ 7-41le_,e= s AI. . . .s 1 Trip permit Dr_coaue4. storage <br /> th <br /> APPLICANT INFORMATION ... <br /> rj Dealer/seller El 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: tmelchior@jandmhomes.com <br /> HOME INFORMATION (* required) :... <br /> Home ID number(if known): , e / DMV X-plate number(if known): <br /> E 3(00 <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: [' Coming out of county deed records <br /> Other:Brand new home • <br /> Manufacturer:CMH Model:72GSA30743DH20 Year:2020 <br /> Manufacturer serial number HUD number <br /> ALB040047ORA <br /> ALB040047ORB <br /> ALB040047ORC <br /> *Number of sections:3 :. *Square footage:2220 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Cement Lap *Heating:Electric *Cooling:None <br /> *Date of sale:7/21/20 *Sales price:146513 *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 /> ❑■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: Dat <br /> J&M Homes, LLC , "b(J 1;LUZv <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 /> 503-908-8166 <br /> 440-2952(7/17/COM) Page 2 <br />