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5 0 q caci 1-1 its 0 k SE , SLt io 1,1 <br /> NATURE OF FILING (check all that applies) <br /> ii • •_ -c . es v a,:. ...rs, . • D: a o' ;•m, .. <br /> J t, . _ - eal : ••- ►1 -.•o.' _ o , . . o, r • . . ❑■ Trip permit Rtzeakst61‘v <br /> USIgier: <br /> APPLICANT INFORMATION .: <br /> LU 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): DMV X-plate number(if known): <br /> A6�W ne35 1 5�J <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:72DRM15663AH20 Year:2020 <br /> Manufacturer serial number HUD number <br /> ALB039290OR <br /> *Number of sections:1 *Square footage:990 *Number of bedrooms:2 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Electric *Cooling:None <br /> *Date of sale:2/28/2020. *Sales price:63567 *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): Dealer signature: Date: /q /1 <br /> J & M Homes, LLC 7/ /z ac) <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 />