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• <br /> 1535(0 Wcxlc�b ; Ws OR St St,i,1*/ yy,.;--1.Li <br /> . . . : .. .:... <br /> NATURE OF FILING (check all that applies) <br /> Ii g- to -s FI ►•. gee , er a D.v o' 'in oat- de • do <br /> • 11., rd 4_;.s ea Bro.-rt • - o ':t: o -al • etus Trip permit e d e..s(olzge <br /> lataer: <br /> APPLICANT INFORMATION <br /> EI 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: dcallahan@jandmhomes.com <br /> HOME INFORMATION (* required) <br /> Home ID number(if known): �{V E, ` / DMV X-plate number(f known): <br /> � <br /> ❑Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> Other:Brand new home <br /> Manufacturer:CMH Model:72DRM28684AH20 Year:2020 <br /> Manufacturer serial number HUD number <br /> ALB0397960RA <br /> ALB039796ORB <br /> *Number of sections:2 *Square footage:1836 *Number of bedrooms:4 *Number of bathrooms:2 <br /> *Type of roofmg:Architectural *Type of siding:Lap Cement *Heating:Electric *Cooling:None <br /> *Date of sale:5/28/20 *Sales price:109167 *Includes land:❑Yes 0 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 /> ❑�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): •i signature: Date: <br /> J &M Homes, LLC DealDIA 8/2 OA 02 <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 <br /> Clackamas, OR 97015 <br /> 503-908-8166 <br /> 440-2952(7/17/COM) Page 2 <br />