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6 Glc, , o f , S poud <br /> NATURE OF FILING (check all that applies) .. , <br /> LYC _ se. rt -re IS . •_• o .a • o . <br /> T e . . r . .,,-rt o g o r:,= p .p;• : . Trip permit ECeraw.efiasl..tntefage <br /> er: <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 /> `_ HOME INFORMATION'-.(*.required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> NEW in358 O <br /> n Moving in from another state <br /> Has no home ID or X-plate because: n Coming out of county deed records <br /> n Other: <br /> Manufacturer:Golden West Model:DRM561 F Year:2019 <br /> Manufacturer serial number HUD number - <br /> ALB039033ORA <br /> ALB039033ORB <br /> *Number of sections:2 *Square footage: 1512 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Comp *Type of siding:T1-11 *Heating:Electric *Cooling:None <br /> *Date of sale:8/15/19 *Sales price:91,598.00 *Includes land: ❑ Yes 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 /> ❑■ 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 <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 Clackamas, OR 97015 <br /> 503-908-8166 <br /> 440-2952(7/17/COM) Page 2 <br />