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• <br /> rz r �i� ? NATURE�OF�FILING`(check all that applies.)r...,, ,:.{ arr r°. ..`. . ; <br /> 12 ' - - •• • • - ro.ert st, s 0 Trip permit <br /> rLJ v•"" j t s fC r f 4{ } r" "� E <br /> APPLICANT INFORMATION75 rr <br /> 0 Dealer/seller � -�--=^ --- - -.resentative-- - <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:apowell@jandmhomes.com <br /> f �F z r HOME INFORMATION (' required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> M355)3O <br /> ❑ Moving in from another state <br /> Has no home ID or X-plate because: ❑ Coming out of county deed records <br /> IM Other:Brand new home <br /> Manufacturer:CMH Model:9596S Year:2018 <br /> Manufacturer serial number HUD.number <br /> HER0310170RA <br /> HER031017ORB <br /> *Number of sections:2 *Square footage:2140 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Composition *Type bf siding:Lap Cement *Heating:Electric *Cooling:None <br /> *Date of sale:1/21/18 *Sales price:141140 *Includes land: ❑Yes Q No <br /> �;• r �� ��•"SvY <br /> ,,: ;, > ` ` ��* DEALIf=R INFPRMA,TION (ibla <br /> f no dealer, lease <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 /> 111 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): Dealer signature: • Date: <br /> J & M Homes LLC /6-4/111,811 3/a2 s/ <br /> a i }'S : .di t ?r�5 ,rtr r r ,. � 4 r �. � _ ., "r ✓�' x -, <br /> 0 f• �. r, t`T,RANSPORTER`INFORMATIOnot m <br /> N,ti oving leave blank) <br /> .. %,r{i ,-�5� .vJ���'. ....w°-.,�.h•.,.� x'v ..,_..?.,.. r. ,fit..,-., � _yf,._. 5{,.� . _... ��rF, ,. ._`fl v.r„,F,''.. .r.'-X<.e5....,... <br /> Transporter name: Transporter address and phone: <br /> 7- 1 5 E g� th .11-v Q- 4 IUd <br /> IA/ cyg 916 i <br /> 440-2952(7/17/COM) Page 2 <br />