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Sre ,— Gcul—e_s 6-1-731-(0 <br /> SECTION 1 NATURE OF FILING(check all that apply) <br /> ❑ New home to MHODS D Adding or removing a co-owner ❑ Demolition(Date: ) <br /> ❑ Used home sale ❑ Recording as real property ❑ Converted to storage <br /> ❑ Security interest change ❑ Removing from real property status 0 Trip Permit <br /> ❑ Transfer by inheritance ❑ Other(please note): <br /> SECTION 2 ' APPLICANT INFORMATION(please print) <br /> Dealer/Seller ❑ Lender ❑Escrow/Title Agent ❑Owner/Buyer ❑Legal Representative <br /> Name:J&M Homes LLC(first,middle,Iasi) Phone:51-928-1.471: <br /> Address:33213 Hwy 34 SE <br /> City:Albany State:OR ZIP:97322 <br /> Email:Isimon@jandmhomes.com . <br /> SECTION 3. HOME INFORMATION(information in bold is required) . <br /> Home ID#: OR No Home ID: New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer:CMH (: e7 1 Q 1 u n 5`�88(a <br /> Model:72DRM28483CH23 Year:2023 <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> ALB0424370RA NTA2171196 <br /> ALB042437ORB NTA2171197 <br /> • <br /> of Sections:• 2 Sq.footage: 1512 Bedrooms: 3 Bathrooms: 2 <br /> Roofing type:. Architectural Siding type: Cement Lap Heating type: Electric :Cooling type:.-•.Heate•Pump <br /> Date of sale:. 11/6/22 Sale price: 139678 Includes land: ❑Yes 0 No -` •••' <br /> • afapplicable) <br /> SECTION 4 DEALER INFORMATION(leave blank if no dealer) . • <br /> Name:J&M Homes LLC License#: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 understand it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature: Date: <br /> SECTION 5 • HOME LOCATION <br /> Current Address:33213 Hwy 34 SE <br /> City:Albany County:Linn State:OR Zip:97322 <br /> Park Name: (if applicable) ®This is a dealer lot or storage facility <br /> 0 This home is being moved to a new location Complete the section below <br /> New Address:133 Fir Street <br /> City:Gates County:Marion State:OR Zip:97346 <br /> Name: I applicable) ❑This is a dealer lot or storage facility <br /> a (f pp ) <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 />