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~ <br />~ <br />. , .~ : ~ <br />Oregon Department of T~ansportation <br />~-~ ~ ~ : . ~~s~~- <br />~ ~ ,~ ~~~e <br />~~~ RELOCATION <br />~0"~XED PAYMENT APPLICATION <br />Name of Q(~acetl Orqanizatlon ~ /~~ L~ <br />~ L- Z ~ ~ V v % <br />M2diny ACCfesi ~ <br />S C.o ~ <br />~.\e <br />Owner: ~~ . <br />`--27~.~t.. ~Q-v~il! c_1-~ <br />7eiepnone Numoer <br />H j~Business p Farm ,- p Non-Profit ~~ <br />! <br />File No <br />Name <br />s~~p~ <br />H~qnway <br />Counry <br />FAP No. <br />I hereby apply for the tfixed payment in lieu of reimbursement for ali other moving and related costs and <br />expenses. I certify that: <br />~i am the owner of the above business, farm operation, or non-p~ofit organizatiort and that this business, <br />farm, or non-profit organization is lawfully located on the real property from which my personal property <br />will be required to be moved. This business , farm, or non-profit organization has been in continuous <br />operation since 1 c~ ti~ - <br />BUSINESS <br />~ This business cannot be relocated without a substantial loss of its existing patronage. <br />This business is not part of a commercial enterprise having more than three other entities which are not <br />ing acquired by the angency, and which are under the same ownership and engaged in the same or <br />similar business activities. - <br />rg'j This business had annual gross receipts of at least $5,000 or had average annual earnings of at least <br />~ <br />31,000; or contributed at least one third of the operator's average annual net income from all sources, <br />during the two taxable years prior to displacement. <br />~The business is not nperated at a displacement dwelling or site solely for the purpose of renting such <br />dwelling or site to others. <br />FARM OPERATION <br />^ The acquisition of the land or part of the land resulted in the displacement of the farm operation, or <br />^ The acquisition caused a substantial change in the nature of the farm operation: <br />NON-PROFIT ORGANIZATION <br />^ The organization cannot be relocated without a substantial loss of existing patronage (membership or <br />clientele). <br />~. ~C.~~~, :~ ~.J ~ ~ ~ 'Z~ 17~ ~ 5'l <br />-A~p ~can e a e T <br />To the best-of my knowledge, this appiicant meets the criteria necessary to qualify for the fixed payment. <br />g` o ay 9en Z.. ~a' S~ t <br />Form 204 (.~ ~~s5) RELOCATION <br />~ ~ FIXED PAYMENT APPLICATION <br />3-~~~~~ Page 1 of 2 pages <br />~ ,~ ~„ . Date _ _ <br />