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I D t u I\ \ocd- e vs GA Q 7 3 5 � <br /> -{N,ATURE OF FILING (check all that applies) <br /> e 1 aik5kp o 1 ' . <br /> � <br /> ,+ . d' :a ' . I •, • :�•:v''• 1 , a se t. . 1 Trip permit t rage <br /> � <br /> iAr: <br /> APPLICANT INFORMATION <br /> Q 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):5 5'U <br /> N W 0 <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> 0 Other:Brand new home <br /> Manufacturer:CMH Model:72PAR28563GH19 Year:2020 <br /> Manufacturer serial number HUD number <br /> ALB0393690RA <br /> ALB0393690RB <br /> *Number of sections:2 *Square footage:1512 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Arcitectural *Type of siding:Wod *Heating:Electric *Cooling:N/A <br /> *Date of sale:11/27/2019 *Sales price:99144 *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 /> 503-908-8166 <br /> UI 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): De le signature: Date: <br /> J &M Homes, LLC M^ I,Df1Mj J 2/13/2020 <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> 440-2952(7/17/COM) Page 2 <br />