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~ <br />Oregon Department of Transportation <br />RELOCATION <br />FIXED PAYMENT APPLICATION <br />Name o! DisplaceC Organization <br />L Z~ ~ <br />Mading Atltlress <br />S ~ <br />~E <br />Owner: <br />~ ~L 1 <br />Telephone NumDer <br />~Business Q Farm ^ Non-Profit <br />! <br />File No <br />Name <br />seaan <br />Hignway <br />councy <br />FAP No <br />f hereby apply for the tfixed payment in lieu of reimbursement for all other moving and related costs and <br />expenses. I certify that: <br />~I am the owner of the above business, farm operation, or non-profit organization 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~ 1 <br />BUSINESS <br />~ This business cannot be relocated without a substantial loss of its existing patronage. <br />~I This business is not part of a commercial enterprise having mo~e than three other entities which are not <br />b~ing acquired by the angency, and which are under the same ownership and engaged in the same or <br />similar business activities. <br />~ This business had annual gross receipts of at least $5,000 or had average annual earnings of at least <br />1,000; 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 operated at a displacement dwelling or site solely for the purpose of renting such <br />dwelling or site to others. <br />FARM OPERATION <br />p The acquisition of the land or part of the land resulted in the disptacement of the farm operation, or <br />p The acquisition caused a substantial change in the nature of the farm operation. <br />NON-PROFIT ORGANIZATION <br />p The organization cannot be relocated without a substantial loss of existing patronage (membership or <br />clientele). <br />,~ ~,~,-'~ e ~ ~ ~ ~ z~ -31 ti, <br />P,~~ T e a e <br />To the best of my knowledge, this applicant meets the criteria necessary to qualify for the fixed payment. <br />~ Z 57 <br />g p ay 9~ a <br />Form 204 (11/95) RELOCATION <br />FIXED PAYMENT APPLICATION <br />Page 1 of 2 pages <br />