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(10 1 1 S 1..CkNi 'IC, V.\ CR CI St 71., r/ <br /> y n er t -1 <br /> 92 <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> e v lfdate-te-AaIrSta- 't1 I tgflo t U is-erMer ❑ en�etl'tio at )D‘pgaLleopeute,,, 1 We s tga/4 y er d let e _ ._. <br /> • e r ' r t et r alas El Trip Permit _ . <br /> ackikjenae Lr i _ <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> _ .. .. - ... . 0 Dealer/Seller ❑Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name:J&M;Homes LLC Phone:541-928-1.47.1 <br /> (first,middle,last) . <br /> Address:33213 Hwy 34 SE . <br /> City:Albany State:OR ZIP:97322 <br /> . Emai►:Isimon@jandmhomes.com <br /> SECTION 3 HOME INFORMATION (information in bold is required) <br /> Home ID#: OR No Home ID: Q New Home El Out of state home ['Leaving.County Deed Records ' <br /> Manufacturer:CMH (,b`1 C D-3 <br /> Model:721 N G42603AH 23 Year:2023 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> - ... ALB0423940RA NTA2163451 .. <br /> - ALB042394ORB NTA2163452 - <br /> - - ALB042394ORC NTA2163453 - <br /> _ <br /> - #of Sections:' 3 -_-.. Sq.footage: 2360 Bedrooms: 3 Bathrooms: :3 <br /> Roofing type Architectural Siding type: Vertical Wood heating type: Electric Cooling type: .None- 1 <br /> ....- <br /> -'-Date ofsale 2/14/23 Sale rice: - . __ _- - <br /> (Ifappltcable) p 236918 Includes land: ❑Yes ❑■ No <br /> SECTION.4 DEALER INFORMATION(leave blank if no dealer) <br /> Name:J&M Homes LLC License II MSD155 <br /> first,middle,last) <br /> 'Address:15850 S Pope Lane <br /> City:Oregon City State:OR ZIP:97045. __ <br /> Email:dasla@jandmhomes.com Phone:503-908-8166 _... <br /> .I hereby declare 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 or my interest in it. The information listed is true to the best of my knowledge and <br /> belief,and I unders nd it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature:�i 7 1 /6,011) Date:'/v;, 3 <br /> SECTION 5 HOME LOCATION <br /> Current Address:2445 Pacific Blvd SW <br /> City:Albany County:Linn State:OR Zip:97321 <br /> Park Name:.(f applicable) ❑This is a dealer lot dr storage facility <br /> ... .. .•K This home is being moved to a new location Complete the section below <br /> New Address:6217 Stayton Rd SE .. <br /> City:Turner County:Marion State:OR Zip:97392 <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name:J&M Homes LLC Phone: 541-928-1471 <br /> Address:33213 Hwy 34 SE City: Albany State: OR <br /> Email:Isimon@jandmhomes.com <br /> • Page 2 <br />